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Management of gastric outlet obstruction caused by ovarian cancer
GYNECOLOFIC
ONCOLOGY
40, 277-279
(1991)
CASE REPORT Management of Gastric Outlet Obstruction Caused by Ovarian Cancer WILLIAM Division
of Gynecologic
J. MANN,*” Oncology,
PATRICIA T. CALAYAG,* JOHN P. MUFFOLETTO,* AND JACK DEITCH~ *Department
of Obstetrics and Gynecology, and tDepartment Stony Brook, Stony Brook, New York 117943091
FRANK ROSS,* EVA CHALAS,* of Radiology,
State University
of New
York
at
Received August 14, 1990
Three patientswith ovarian cancerwho developedgastricoutlet
obstruction due to loculatedascitesin the lesseromental sacare presented.Surgical decompression wasutilized, in one casewith significant morbidity. Percutaneousdrainageunder CT or ultrasoundguidanceallows palliation and avoids potential morbidity and prolongedhospitalizationand can berepeatedif the condition recurs. 0 1991 Academic Press, Inc.
In the calendar year 1990, it is estimated 12,400 women will die of ovarian cancer with some component of bowel obstruction complicating their terminal course. In approximately 20% of patients, large bowel obstruction will usually require colostomy, while small bowel obstruction, occurring in over 50%, can be treated surgically with a risk of significant morbidity and mortality, or with decompression by nasogastric or long intestinal tube [2,3]. A small subset of these women will suffer gastric outlet obstruction caused by loculated ascites in the lesser omental sac. It is important to recognize this group of women, since in our experience, these patients are best managed by percutaneous catheter drainage of the ascites, which avoids the dangers of operative intervention and allows the patients to maximize time at home. CASE HISTORIES A. A 38-year-old gravida 2 white female underwent a TAH/BSO, omentectomy, and optimal cytoreductive surgery for Stage IIIC ovarian cancer. Shen then underwent eight courses of Cytoxan, Adriamycin, and cisplatinum
’ To whom reprint requests should be addressed at: Division of Gynecologic Oncology, Health Sciences Center T9-092, State University of New York at Stony Brook, Stony Brook, New York 11794-8091.
(CAP). A planned “second-look” procedure was negative and she did well for 30 months. Ascites developed, and surgical exploration confirmed unresectable miliary recurrence. Multiple chemotherapeutic salvage regimens were unsuccessfully attempted, and 13 months after recurrence she was hospitalized with the clinical diagnosis of bowel obstruction. Placement of a nasogastric tube relieved vomiting and drained 3-4 liters per day. Supine and erect abdominal films showed no obstruction. An upper GI series revealed extrinsic gastric outlet obstruction, and at laparotomy loculated ascites in the lesser omental sac was drained. The obstruction resolved, but massive adhesions due to miliary disease led to major blood loss and multiple enterotomies. Postoperatively, the patient deteriorated over 2 weeks and died. B. A 62-year-old gravida 3 white female underwent a TAH/BSO, omentectomy, and optimal cytoreductive surgery for Stage IIIC ovarian cancer. She received eight courses of CAP and had a positive second-look procedure. Whole abdominal irradiation was given, but 4 months later she presented with apparent bowel obstruction. Nasogastric drainage was high and supine and erect films of the abdomen were nondiagnostic. A CT scan demonstrated gastric outlet obstruction secondary to loculated ascites in the lesser sac (Fig. 1). Percutaneous drainage under fluouroscopic control using local anesthesia relieved the obstruction and the patient returned home with her family and died 3 months later (Fig. 2). C. A 58-year-old gravida 3 presented with Stage IIIC ovarian cancer. Initial surgical exploration led to suboptimal tumor resection and she received four courses of CAP. Tumor regressed and at reexploration complete resection of cancer was possible. Four additional courses of CAP were given but tumor regrowth occurred. Gastric
277
All
OWO-8258/91 $1.50 Copyright 0 1991 by Academic Press. Inc. rights of reproduction in any form reserved.
278
MANN ET AL.
FIG. 1. Arrow indicates large fluid collection in lesser omental sac.
outlet obstruction occurred due to loculated ascites in the lesser sac, which presented on abdominal examination as a fluid-filled left upper quadrant mass. Reexploration again allowed optimal cytoreduction as well as relief of obstruction. Multiple chemotherapeutic regimens were instituted, without success. Gastric outlet obstruction recurred and loculated ascites was drained under CT guidance as an outpatient procedure. Therapy was discontinued. Several months later, gastric outlet obstruction again recurred and was again drained under CT guidance as an outpatient procedure. The patient has remained at home with her family for over a year without recurrent obstruction. DISCUSSION Aggressive surgery aimed at complete tumor resection remains the key to treating ovarian cancer. Evidence that repeated attempts at cytoreductive surgery may improve survival, or quality of life, is accumulating. However, the majority of patients presenting with advanced ovarian cancer will suffer some component of bowel obstruction and ultimately die of their disease.
Several extensive articles on ovarian cancer and bowel obstruction fail to mention gastric outlet obstruction [1,4,5]. Katz et al. reported two cases, both managed by laparotomy with bypass of large extrinsic masses obstructing the pylorus [6]. Krebs et al. also reported two patients with ovarian cancer who had loculated ascites causing gastric outlet obstruction [7]. One was treated by laparotomy, while the second was drained by paracentesis. These authors emphasize that gastric outlet obstruction differs from small bowel obstruction in that the patient has upper abdominal constant pain, absence of rushing peristalsis, and no air-fluid levels on erect films of the abdomen. Our experience suggests that either surgical decompression or percutaneous drainage will alleviate gastric outlet obstruction due to loculated ascites. However, the condition can recur whether treated surgically or not. Therefore, we believe and recommend that percutaneous drainage should be utilized instead of surgical intervention. This minimizes time in the hospital and symptomatically improves the lot of these unfortunate women. Repeated drainage can be accomplished as an outpatient procedure under CT or ultrasound guidance.
CASE REPORT
279
FIG. 2. Catheter lies in lesser omental sac.
REFERENCES 1. Silverberg, 1990. Cu2. Krebs, H. in patients J. Obstet.
E., Boring, C. C., and Squires, T. S. Cancer statistics, J. Cl&. 40, 9-26 (1990). B., and Goplerud, D. R. Mechanical intestinal obstruction with gynecologic disease: A review of 368 patients, Am. Gynecol. 157, 577-583 (1987). Cancer
3. Chalas, E., Mann, W. J., Westermann, C. P., and Patsner, B. Morbidity and mortality of stapled anastomoses on a gynecologic oncology service: A retrospective review, Gynecol. Oncol. 37, 82-86 (1990). 4. Castaldo, T. W., Petrillo, E. S., Ballon, S. C., and Lagasse, L. D.
Intestinal operations in patients with ovarian cancer, Am. J. Obstet. Gynecol. 139, 80-89 (1981). 5. Tunca. J. C., Bucher. D. A., Mack, E. A., Rugicka, F. F., Crowley, J. J., and Carr, W. E. The management of ovarian cancer caused bowel obstruction, Gynecol. Oncol. 12, 186-192 (1981). 6. Katz, L. B.. Frankel, A., Cohen, C., and Slater, G. Ovarian carcinoma complicated by gastric outlet obstruction, J. Surg. Oncol. 18, 261-264 (1981). 7. Krebs, H. B., Walsh, J., and Goplerud, D. R. Gastric outlet obstruction caused by ascitic fluid entrapment in the lesser sac-A complication of ovarian cancer: Report of two cases, Gynecol. Oncol. 14, 105-111 (1982).
ONCOLOGY
40, 277-279
(1991)
CASE REPORT Management of Gastric Outlet Obstruction Caused by Ovarian Cancer WILLIAM Division
of Gynecologic
J. MANN,*” Oncology,
PATRICIA T. CALAYAG,* JOHN P. MUFFOLETTO,* AND JACK DEITCH~ *Department
of Obstetrics and Gynecology, and tDepartment Stony Brook, Stony Brook, New York 117943091
FRANK ROSS,* EVA CHALAS,* of Radiology,
State University
of New
York
at
Received August 14, 1990
Three patientswith ovarian cancerwho developedgastricoutlet
obstruction due to loculatedascitesin the lesseromental sacare presented.Surgical decompression wasutilized, in one casewith significant morbidity. Percutaneousdrainageunder CT or ultrasoundguidanceallows palliation and avoids potential morbidity and prolongedhospitalizationand can berepeatedif the condition recurs. 0 1991 Academic Press, Inc.
In the calendar year 1990, it is estimated 12,400 women will die of ovarian cancer with some component of bowel obstruction complicating their terminal course. In approximately 20% of patients, large bowel obstruction will usually require colostomy, while small bowel obstruction, occurring in over 50%, can be treated surgically with a risk of significant morbidity and mortality, or with decompression by nasogastric or long intestinal tube [2,3]. A small subset of these women will suffer gastric outlet obstruction caused by loculated ascites in the lesser omental sac. It is important to recognize this group of women, since in our experience, these patients are best managed by percutaneous catheter drainage of the ascites, which avoids the dangers of operative intervention and allows the patients to maximize time at home. CASE HISTORIES A. A 38-year-old gravida 2 white female underwent a TAH/BSO, omentectomy, and optimal cytoreductive surgery for Stage IIIC ovarian cancer. Shen then underwent eight courses of Cytoxan, Adriamycin, and cisplatinum
’ To whom reprint requests should be addressed at: Division of Gynecologic Oncology, Health Sciences Center T9-092, State University of New York at Stony Brook, Stony Brook, New York 11794-8091.
(CAP). A planned “second-look” procedure was negative and she did well for 30 months. Ascites developed, and surgical exploration confirmed unresectable miliary recurrence. Multiple chemotherapeutic salvage regimens were unsuccessfully attempted, and 13 months after recurrence she was hospitalized with the clinical diagnosis of bowel obstruction. Placement of a nasogastric tube relieved vomiting and drained 3-4 liters per day. Supine and erect abdominal films showed no obstruction. An upper GI series revealed extrinsic gastric outlet obstruction, and at laparotomy loculated ascites in the lesser omental sac was drained. The obstruction resolved, but massive adhesions due to miliary disease led to major blood loss and multiple enterotomies. Postoperatively, the patient deteriorated over 2 weeks and died. B. A 62-year-old gravida 3 white female underwent a TAH/BSO, omentectomy, and optimal cytoreductive surgery for Stage IIIC ovarian cancer. She received eight courses of CAP and had a positive second-look procedure. Whole abdominal irradiation was given, but 4 months later she presented with apparent bowel obstruction. Nasogastric drainage was high and supine and erect films of the abdomen were nondiagnostic. A CT scan demonstrated gastric outlet obstruction secondary to loculated ascites in the lesser sac (Fig. 1). Percutaneous drainage under fluouroscopic control using local anesthesia relieved the obstruction and the patient returned home with her family and died 3 months later (Fig. 2). C. A 58-year-old gravida 3 presented with Stage IIIC ovarian cancer. Initial surgical exploration led to suboptimal tumor resection and she received four courses of CAP. Tumor regressed and at reexploration complete resection of cancer was possible. Four additional courses of CAP were given but tumor regrowth occurred. Gastric
277
All
OWO-8258/91 $1.50 Copyright 0 1991 by Academic Press. Inc. rights of reproduction in any form reserved.
278
MANN ET AL.
FIG. 1. Arrow indicates large fluid collection in lesser omental sac.
outlet obstruction occurred due to loculated ascites in the lesser sac, which presented on abdominal examination as a fluid-filled left upper quadrant mass. Reexploration again allowed optimal cytoreduction as well as relief of obstruction. Multiple chemotherapeutic regimens were instituted, without success. Gastric outlet obstruction recurred and loculated ascites was drained under CT guidance as an outpatient procedure. Therapy was discontinued. Several months later, gastric outlet obstruction again recurred and was again drained under CT guidance as an outpatient procedure. The patient has remained at home with her family for over a year without recurrent obstruction. DISCUSSION Aggressive surgery aimed at complete tumor resection remains the key to treating ovarian cancer. Evidence that repeated attempts at cytoreductive surgery may improve survival, or quality of life, is accumulating. However, the majority of patients presenting with advanced ovarian cancer will suffer some component of bowel obstruction and ultimately die of their disease.
Several extensive articles on ovarian cancer and bowel obstruction fail to mention gastric outlet obstruction [1,4,5]. Katz et al. reported two cases, both managed by laparotomy with bypass of large extrinsic masses obstructing the pylorus [6]. Krebs et al. also reported two patients with ovarian cancer who had loculated ascites causing gastric outlet obstruction [7]. One was treated by laparotomy, while the second was drained by paracentesis. These authors emphasize that gastric outlet obstruction differs from small bowel obstruction in that the patient has upper abdominal constant pain, absence of rushing peristalsis, and no air-fluid levels on erect films of the abdomen. Our experience suggests that either surgical decompression or percutaneous drainage will alleviate gastric outlet obstruction due to loculated ascites. However, the condition can recur whether treated surgically or not. Therefore, we believe and recommend that percutaneous drainage should be utilized instead of surgical intervention. This minimizes time in the hospital and symptomatically improves the lot of these unfortunate women. Repeated drainage can be accomplished as an outpatient procedure under CT or ultrasound guidance.
CASE REPORT
279
FIG. 2. Catheter lies in lesser omental sac.
REFERENCES 1. Silverberg, 1990. Cu2. Krebs, H. in patients J. Obstet.
E., Boring, C. C., and Squires, T. S. Cancer statistics, J. Cl&. 40, 9-26 (1990). B., and Goplerud, D. R. Mechanical intestinal obstruction with gynecologic disease: A review of 368 patients, Am. Gynecol. 157, 577-583 (1987). Cancer
3. Chalas, E., Mann, W. J., Westermann, C. P., and Patsner, B. Morbidity and mortality of stapled anastomoses on a gynecologic oncology service: A retrospective review, Gynecol. Oncol. 37, 82-86 (1990). 4. Castaldo, T. W., Petrillo, E. S., Ballon, S. C., and Lagasse, L. D.
Intestinal operations in patients with ovarian cancer, Am. J. Obstet. Gynecol. 139, 80-89 (1981). 5. Tunca. J. C., Bucher. D. A., Mack, E. A., Rugicka, F. F., Crowley, J. J., and Carr, W. E. The management of ovarian cancer caused bowel obstruction, Gynecol. Oncol. 12, 186-192 (1981). 6. Katz, L. B.. Frankel, A., Cohen, C., and Slater, G. Ovarian carcinoma complicated by gastric outlet obstruction, J. Surg. Oncol. 18, 261-264 (1981). 7. Krebs, H. B., Walsh, J., and Goplerud, D. R. Gastric outlet obstruction caused by ascitic fluid entrapment in the lesser sac-A complication of ovarian cancer: Report of two cases, Gynecol. Oncol. 14, 105-111 (1982).