Matthias W. Wichmann and Guy Maddern (eds.)Palliative Surgery201410.1007/978-3-642-53709-7_14
© Springer-Verlag Berlin Heidelberg 2014
14. Small Bowel
(1)
Department of General Surgery, Mount Gambier General Hospital, Flinders University—Rural Medical School, 276 Wehl Street North, Mount Gambier, SA, 5290, Australia
14.1 Introduction
14.5.1 Fitness for Surgery
14.5.2 Oncologic Treatment Options
14.5.3 Prognosis
14.7 Surgical Technique
14.8 Emergencies
14.10 Conclusion/Summary
Abstract
Malignant small bowel obstruction is frequently seen in patients suffering from peritoneal carcinomatosis. Primary cancers of the small bowel are rare but due to late diagnosis also can present with obstruction. In the case of peritoneal carcinomatosis, the primary cancer usually is not localized within the small bowel. Primary lesions in these patients most commonly are in the large bowel, stomach, ovaries or pancreas. Surgery is the treatment of choice for the cure as well as palliation of small bowel cancers. In a palliative situation, treatment most of all must follow the principle to “first do no harm”, and decisions must be based on the patient’s wishes, fitness for surgery, oncologic treatment options and prognosis. If the patient is considered fit for surgery, only a short conservative treatment attempt should be made followed by surgery. If possible, enteroenteric bypass should be preferred over stoma formation. Peritoneal carcinomatosis should be assessed using the Peritoneal Cancer Index prior to treatment planning. In patients unfit for surgery, stent insertion (endoscopic or radiological), venting gastrostomy and feeding jejunostomy should be considered depending on symptoms. Medical treatment of nausea and vomiting as well as analgesia must be provided in close cooperation with the palliative care team.
14.1 Introduction
When treatment objectives change from cure to palliation, the maxim “primum non nocere” – most of all do no harm – must be at the centre of all surgical and medical decisions.
Involvement of the small bowel within peritoneal carcinomatosis is a common finding with various malignancies. Primary malignancies of the small bowel continue to be a rare diagnosis but appear to be on the rise.
14.2 Primary Small Bowel Malignancies
Less than 3 % of gastrointestinal malignancies arise from the small bowel [1]. The annual incidence has been reported to vary between 9.9 and 19.7 per million people [2, 3]. The SEER data review of malignant small bowel tumours by Chow et al. [2] indicates that the four most common histological types of cancer within the small bowel are:
Other primary lesions of the small bowel are gastrointestinal stromal tumours (GIST) and small cell carcinoma [5, 11].
Most patients (90 %) are older than 40 years of age at the time of diagnosis. Due to unusual symptoms, the rarity of the disease as well as difficult imaging of the small bowel, the diagnosis is frequently made with a significant delay [1, 2].
Surgery is the treatment of choice for the cure as well as palliation of small bowel cancers.
14.3 Peritoneal Carcinosis/Carcinomatosis
The peritoneal cavity and the small intestine are frequently involved with advanced intra- as well as extra-abdominal malignancies. Usually, the primary cancer is not localized within the small bowel.
Malignancies frequently associated with peritoneal carcinomatosis are colorectal cancer (up to 30 % of all patients), gastric cancer (up to 50 % of all patients), ovarian cancer (up to 80 % of patients with first diagnosis) and pancreatic cancer (up to 10 % of all patients). In approximately 5 % of patients with CUP syndrome (carcinoma of unknown primary), peritoneal involvement can be observed [12, 13]. Other cancers known to involve the small bowel are malignant melanoma and lung cancer [14–18].
The extent of peritoneal involvement can be assessed with the Peritoneal Cancer Index (PCI), which was first described by Sugarbaker et al. [19]. This index evaluates 12 areas within the abdomen, and the tumour involvement is graded from 0 (not visible) to 3 (larger than 5 cm). The maximum PCI score is 39, and a score below 13 has been reported to be associated with better survival [20]. A PCI of less than 20 indicates a potential for multimodal treatment (cytoreductive surgery + intraoperative chemotherapy followed by systemic chemotherapy) with curative intent [1]. This option must always be considered when assessing a patient with peritoneal carcinosis.
14.4 Small Bowel Obstruction: To Operate or Not to Operate?
Decision making on whether or not to operate on a patient presenting with small bowel obstruction can be difficult. The decision depends on the patient’s wishes, the disease prognosis as well as the patient’s performance status.
A study by Zielinski et al. [21] revealed that free intraperitoneal fluid, mesenteric oedema, lack of faeces in the small bowel and vomiting are independent predictors favouring surgical exploration in patients with small bowel obstruction. Within the context of palliative surgery, however, patient performance status and disease prognosis are of special relevance for the decision-making process.
14.5 Preoperative Considerations
14.5.1 Fitness for Surgery
Fitness for surgery should be assessed by a team approach including the surgeon and the anaesthetist. It is best to discuss surgical goals and intraoperative risks with the patient and his or her family while both the surgeon and the anaesthetist are present. This approach avoids misunderstanding and poor information of the patient regarding the expected procedure and the potential benefits/risks of the intervention. Optimization of patient physiology – within the limits of bowel obstruction – should be attempted immediately before surgery.
14.5.2 Oncologic Treatment Options
Absence of or existing oncologic treatment options are of relevance for the treatment decision. Recent years have seen significant improvement of palliative chemotherapy as well as radiation treatment regimens (see Chaps. 23 and 24). This is of significance since surgical trauma and/or complications may delay the start of palliative chemotherapy/radiotherapy in some patients, while other patients may benefit from tumour debulking prior to the start of palliative chemotherapy and/or radiotherapy. Close cooperation between the surgeon, the medical oncologist and the radiation oncologist are of great importance to achieve best treatment results in this setting.
The decision for or against surgery should not only be based on the question whether or not this intervention is technically possible and will be survived by the patient. This necessitates close cooperation between different fields of medicine, and it can best be achieved within the setting of a multidisciplinary care team. This approach also allows for additional contributions from palliative care and dieticians. Careful documentation of the treatment recommendation is of great importance since a number of the decisions made within this setting cannot be based on reliable evidence and are usually tailored for the individual patient.
14.5.3 Prognosis
Malignant small bowel obstruction carries a poor prognosis and usually survival is not expected to exceed 1 year [12]. With regard to this, it is important to note that patients who already survived for a long period of time with inoperable cancer have a better prognosis than those who have only recently been diagnosed with the same disease (the so-called conditional survival) (see Chap. 23). Consideration of the underlying disease process and knowledge about “conditional survival” are important for the decision making within the setting of palliative surgery for malignant small bowel obstruction as well as other conditions.
14.6 Patient Fit for Surgery
Provided that clinical factors indicate that the patient will survive surgery, only a short trial of nasogastric decompression should be made [13].
Escalation of treatment in the setting of malignant bowel obstruction has been reported to improve survival but at the same time puts a significant financial burden on the system, and patients do suffer from significant morbidity and mortality [22]. Within the multitude of disease processes that can lead to malignant small bowel obstruction, patients with primary colorectal cancer appear to have better survival and palliation when treated with surgical intervention for malignant small bowel obstruction [23].
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