Challenges and outcome of surgery for bowel obstruction in women with gynaecologic cancer.

INTRODUCTION: Bowel obstruction is associated with a reduction in quality of life and survival among cancer patients, and the entity is traditionally treated by general surgeons without dedication to the different malignancies that cause bowel obstruction or to palliation. This study aims to identify and improve outcome of bowel obstruction in women with a history of a gynaecologic cancer. METHODS: Women operated for bowel obstruction were screened for a history of gynaecologic cancer and their records were reviewed. RESULTS: Bowel obstruction followed cancer treatment by a median of 18.4 months (range 2.3-277) in 59 women. A malignant cause was identified in 53% and recurrence of cancer in 61%. The cause of malignant bowel obstruction was peritoneal carcinomatosis (19%), obstructing tumour and carcinomatosis (31%) and solitary tumour (3%). Ovarian cancer (OR: 6.29, 95% CI 1.95-20.21), residual tumour during initial surgery (R2-stage) (OR: 18.7, 96% CI: 4.35-80.46) and chemotherapy (OR: 7.19, 95% CI: 2.28-22.67) were all associated with malignant bowel obstruction. Surgery solved 84% of malignant bowel obstructions, but median survival was brief (2.5 months, 95% CI: 1.4-3.6) when compared to benign bowel obstruction (95.3 months, 64.7-125.9) (p < 0.001). Readmission for bowel obstruction occurred after a median of 4.3 months (95% CI: 3.1-5.5) in surviving patients with malignant bowel obstruction and after a median of 84.5 months (95% CI: 73.6-95.3) with adhesive obstruction (p < 0.001). CONCLUSIONS: Increased awareness of the aetiology to bowel obstruction may improve treatment strategy in these women. Women with malignant bowel obstruction should be carefully identified and differentiated in order to improve quality of life rather than pursuing emergency surgical procedures.

Chronic constipation and treatment options (Review).

Chronic constipation (CC) is a highly prevalent heterogeneous disorder. Although CC is not known to be associated with the development of serious disease or with excess mortality, it considerably reduces the patients quality of life. In addition, it represents an economic burden to patients and society. The majority of patients with CC successfully manage the disorder by dietary management and the use of laxatives. Patients with functional CC (slow­transit and non­slow transit constipation) do not respond to laxatives and are a small fraction of the total population complaining of constipation. Regardless of the low number of these patients, the intractability of their symptoms causes psychological and social stress and greatly impairs their quality of life. Furthermore, these patients consume a disproportionate quantity of medical resources. It appears that these patients have a disturbance in the serotonin transmission system, which results in a cascade of alterations in a number of gut neuroendocrine hormones/transmitters. The effect of prucalopride, a serotonin receptor agonist, in this category of patients appears to be not only a pharmacological prokinetic action, but also a correction of a pre­existing disturbance. Linaclotide, a member of the guanylin peptide family, binds to the ligand­binding region of guanylate cyclase­C on the luminal surface of gastrointestinal epithelia resulting in increased fluid secretion. This drug has also been found to be effective for the treatment of functional CC. In addition, biofeedback and sacral nerve stimulation are effective in the treatment of CC caused by pelvic floor disorders.

Increased incidence of postoperative infections during prophylaxis with cephalothin compared to doxycycline in intestinal surgery.

BACKGROUND: The antibiotics used for prophylaxis during surgery may influence the rate of surgical site infections. Tetracyclines are attractive having a long half-life and few side effects when used in a single dose regimen. We studied the rate of surgical site infections during changing regimens of antibiotic prophylaxis in medium and major size surgery. METHODS: Prospective registration of surgical site infection following intestinal resections and hysterectomies was performed. Possible confounding procedure and patient related factors were registered. The study included 1541 procedures and 1489 controls. The registration included time periods when the regimen was changed from doxycycline to cephalothin and back again. RESULTS: The SSI in the colorectal department increased from 19% to 30% (p=0.002) when doxycycline was substituted with cephalothin and decreased to 17% when we changed back to doxycycline (p=0.005). In the gynaecology department the surgical site infection rate did not increase significantly. Subgroup analysis showed major changes in infections in rectal resections from 20% to 35% (p=0.02) and back to 12% (p=0.003). CONCLUSION: Doxycycline combined with metronidazole, is an attractive candidate for antibiotic prophylaxis in medium and major size intestinal surgery.

[Nausea, vomiting and constipation in palliative care]. / Kvalme, oppkast og obstipasjon i palliasjonsbehandling.

Nausea/vomiting and constipation are frequent symptoms among patients with advanced disease and short survival expectancy. The aim of this paper is to present the aetiology, diagnostic work-up, prophylaxis and treatment of these symptoms in palliative patients, based on a literature review and clinical experience. Nausea/vomiting is not a diagnosis, but symptoms with multiple causes. There is no universally applicable treatment approach. General guidelines for good treatment are: 1) impeccable assessment and work-up, 2) choice of treatment according to underlying causes and involved mechanisms, 3) pharmacological treatment applied jointly with non-pharmacological measures, 4) thorough follow-up and readjustment of treatment. During work-up, or if underlying causes can not be identified, metoclopramide, alternatively haloperidol, is the first drug of choice. Oral administration should be avoided until vomiting is controlled. Adequate hydration is important. The same general guidelines are applicable to handle constipation. However, prophylactic measures are also essential, focusing on risk factors (fluid intake, activity and toilet accommodations). Stool softening laxatives should be administered, (polyethylene glycol or lactulose), and if needed, combined with a bowel stimulant (bisacodyl or sodium picosulphate). Opioid use is among the most common causes of constipation and prescription of opioids should always be accompanied by prescription of laxatives. Exceptions are diarrhoea, ileostomy and dying patients.

[Treatment with nutrition and fluids in patients with non-curable cancer]. / Ernaering og vaeskebehandling til pasienter med ikke-kurabel kreftsykdom.

Patients with non-curable cancer represent a large and heterogeneous group in which malnutrition and weight loss is a frequent finding. This article is based on relevant literature and our own clinical experience. For every patient a thorough examination of possible underlying causes should be explored and corrected as soon as possible (secondary cachexia). However, in many patients primary cachexia is the cause, a catabolic condition where muscle protein and lipids are degraded and even aggressive nutrition will not reverse the process. This condition is very different from starvation. Metoclopramide, corticosteroids and gestagens can relieve symptoms as anorexia, chronic nausea and asthenia which frequently occur in patients with cachexia. Treatments that may maintain or increase muscle function and modulate inflammatory processes are new approaches, such as eicosapentaneoic acid, adenosine triphosphate, specific amino acids and nonsteroidal antiinflammatory drugs. Nutrition is an integrated part of supportive therapy to all cancer patients, unless expected survival is short. At this time in life, nutrition will not influence survival and focus should be on symptom control.