Surgical management of bowel obstruction in gynaecological malignancies- Introduction

A Special Author Introduction
Current Opinion in Supportive and Palliative Care

ISSN: 1751-4258 • Frequency: 6/year • Subscribe Now 

By Kolomainen & Barton

 Malignant bowel obstruction is commonly seen in gynaecological malignancies with reported rates of up to 50% in epithelial ovarian cancer (EOC) and is a feature of advanced disease. Bowel obstruction is a common clinical problem in relapsed EOC occurring in up to 35% and it is often an early clinical manifestation of relapsed disease, in which setting it is associated with a poor prognosis. Bowel obstruction in gynaecological malignancies continues to present clinical challenges and a multidisciplinary approach to discuss management is crucial. Surgery, usually with palliative intent, is associated with significant morbidity and mortality. There is absence of level 1 evidence and national guidelines, and only limited quality of life data.

Acute bowel obstruction in gynaecological cancer patients is rare and surgery is associated with a higher morbidity and mortality rate. Less commonly, emergency bowel obstruction cases will have had radiotherapy or recent chemotherapy which also increase surgical morbidity and mortality. However, most often bowel obstruction in irradiated gynaecological cancer patients is not due to cancer. Most gynaecological cancer patients with bowel obstruction present non-acutely and recurrent epithelial ovarian cancer (EOC) being the most common malignancy. These patients have a reduced overall survival compared to those presenting with primary disease without bowel obstruction. It is important to remember that successful palliation may not translate into resolution of symptoms with a re-obstruction rate as high as 26.5% . This is under-reported as most patients will subsequently die of bowel obstruction. Therefore an alternative and necessary strategy is to identify those patients in bowel obstruction who would and those who would not benefit from surgery. Caution is needed in those EOC patients with ascites, short treatment-free interval (TFI), acute abdomen, chemo-resistance, and co-morbidities are frequent. The decision for surgery should be made on an individual basis. Palliative care input is important early in patient management as for most patients the surgical goal is palliation and not cure. There is still a paucity of published data on quality of life assessments.

There is a need to identify those patients who will likely to benefit from palliative surgical intervention and those who will not. Ideally, agreed national guidelines should be produced and regularly reviewed.

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