Small Bowel Obstructions And Gynecologic Malignancies: Conservative, Operative And Palliative Management

Objectives: Small bowel obstructions (SBO) are common in women with gynecologic malignancies. Conservative management is typically the first-line treatment for these patients. However, despite similar initial clinical presentations, some women ultimately require acute surgical interventions or palliative procedures to relieve symptoms. We aimed to characterize and compare these three management options (conservative management, acute intervention and palliative procedures) in order to better understand how to best approach treatment, individualize management, and optimize patient outcomes. Methods: Following IRB approval, ICD-10 codes were utilized to retrospectively identify women with gynecologic malignancies hospitalized for SBO from 2006-2019 at a single academic center. Clinical, treatment, and outcome data were collected. Risk factors were reported using descriptive statistics and compared between treatment groups using Chi-Square/Fisher's exact test for categorical risk factors and Mann-Whitney U test for continuous risk factors. Results: We analyzed 288 admissions from 253 unique patients, of which 229 patients (90.5%) had one admission and 24 (10.4%) had more than one admission. The majority had ovarian cancer (60.4%). Of the 288 admissions, 163 (56.6%) resolved with conservative management, 60 (20.8%) underwent acute surgical intervention, and 65 (22.6%) underwent palliative gastrostomy tube placement. Active cancer on presentation (p=0.005), number of comorbidities (p=0.009), type of obstruction (p=0.001), number of prior chemotherapy lines (p=0.03), platinum resistance (p=0.012), chronic opioid use (p=0.006), and placement of nasogastric tube on admission (p=0.022) were significantly different among the three groups. In pairwise comparison, patients undergoing acute surgical intervention had a lower mean number of comorbidities (1.98 versus 2.66, p=0.017) and were more likely to have a high grade versus partial bowel obstruction (p<0.001) when compared to those who resolved with conservative management. Patients undergoing palliative gastrostomy tube placement had received a higher mean number of prior chemotherapy lines (2.69 versus 2.0, p=0.01), were more likely to have platinum resistance (p=0.003), chronic opioid use (p=0.003), high grade versus partial bowel obstruction (p=0.04), active cancer on presentation (p=0.015), and were more likely to have a nasogastric tube placed on admission (p=0.011) when compared to those who resolved with conservative management. Conclusions: Risk factors for surgical intervention can aid in counseling, medical optimization, and treatment decisions for patients at high risk for failure of conservative management of SBO. In this cohort, patients with high grade obstruction and > 2 medical comorbidities were statistically more likely to fail conservative management, which may suggest need for earlier surgical intervention. Future studies evaluating the management of SBO in patients with gynecologic malignancies across institutions may help in developing a treatment algorithm for this patient population. Small bowel obstructions (SBO) are common in women with gynecologic malignancies. Conservative management is typically the first-line treatment for these patients. However, despite similar initial clinical presentations, some women ultimately require acute surgical interventions or palliative procedures to relieve symptoms. We aimed to characterize and compare these three management options (conservative management, acute intervention and palliative procedures) in order to better understand how to best approach treatment, individualize management, and optimize patient outcomes. Following IRB approval, ICD-10 codes were utilized to retrospectively identify women with gynecologic malignancies hospitalized for SBO from 2006-2019 at a single academic center. Clinical, treatment, and outcome data were collected. Risk factors were reported using descriptive statistics and compared between treatment groups using Chi-Square/Fisher's exact test for categorical risk factors and Mann-Whitney U test for continuous risk factors. We analyzed 288 admissions from 253 unique patients, of which 229 patients (90.5%) had one admission and 24 (10.4%) had more than one admission. The majority had ovarian cancer (60.4%). Of the 288 admissions, 163 (56.6%) resolved with conservative management, 60 (20.8%) underwent acute surgical intervention, and 65 (22.6%) underwent palliative gastrostomy tube placement. Active cancer on presentation (p=0.005), number of comorbidities (p=0.009), type of obstruction (p=0.001), number of prior chemotherapy lines (p=0.03), platinum resistance (p=0.012), chronic opioid use (p=0.006), and placement of nasogastric tube on admission (p=0.022) were significantly different among the three groups. In pairwise comparison, patients undergoing acute surgical intervention had a lower mean number of comorbidities (1.98 versus 2.66, p=0.017) and were more likely to have a high grade versus partial bowel obstruction (p<0.001) when compared to those who resolved with conservative management. Patients undergoing palliative gastrostomy tube placement had received a higher mean number of prior chemotherapy lines (2.69 versus 2.0, p=0.01), were more likely to have platinum resistance (p=0.003), chronic opioid use (p=0.003), high grade versus partial bowel obstruction (p=0.04), active cancer on presentation (p=0.015), and were more likely to have a nasogastric tube placed on admission (p=0.011) when compared to those who resolved with conservative management. Risk factors for surgical intervention can aid in counseling, medical optimization, and treatment decisions for patients at high risk for failure of conservative management of SBO. In this cohort, patients with high grade obstruction and > 2 medical comorbidities were statistically more likely to fail conservative management, which may suggest need for earlier surgical intervention. Future studies evaluating the management of SBO in patients with gynecologic malignancies across institutions may help in developing a treatment algorithm for this patient population.