Section 3: Gynecologic Oncology

PERIOPERATIVE CONSIDERATIONS AND COMPLICATIONS

Bowel Obstruction

Small Bowel Obstructions (SBO)

• Workup may include imaging (abdominal x-ray, CT scan), CBC, CMP, lactate level

• Trial of conservative (nonsurgical) management appropriate if no evidence of perforation, ischemia, or strangulation

  • Bowel rest and decompression with nasogastric (NG) tube are appropriate first steps

  • Start GI prophylaxis with Ranitidine (Zantac) 50 mg IV every 8 hours or proton pump inhibitor [eg, pantoprazole (Protonix)]

  • Replace NG tube output [1 cc NS (or LR) per cc NG tube output every 4 hours] and replete electrolyte losses

Note: If obstruction occurs acutely within 1 week of surgery, high likelihood of requiring surgical intervention

• If conservative management fails

  • Consider risks/benefits of surgical intervention: Consent for exploratory laparotomy, possible bowel resection, possible bypass, possible ostomy

  • Consider preoperative Gastrografin enema to rule out concurrent large bowel obstruction (LBO)

  • Surgery not appropriate in patients with poor prognostic criteria (ie, diffuse intra-abdominal carcinomatosis, multifocal obstruction, poor performance status, or massive ascites)

Note: For women with ovarian cancer and bowel obstruction, data show 90% relieved with surgery, but major morbidity (fistulas and anastomotic leaks) occurred in 32% and perioperative death in 15%. Re-obstruction rate of 10–50%

• If the patient is not a surgical candidate, consider percutaneous endoscopic gastrostomy (PEG) tube

  • Octreotide (100-300 μg subcutaneously 2-3 times daily) can decrease gastric secretions and slow intestinal mobility → decreases nausea/vomiting associated with SBO

  • Obstruction at cancer diagnosis and mucin histology are associated with recurrent obstructions

Large Bowel Obstruction (LBO)

• Rare in ovarian cancer patients

• In general, considered a surgical emergency

• Surgical management generally involves creation of an ostomy

• Endoscopic management with rectal stent is possible in select patients (stable, no peritoneal signs, partially obstructed, poor surgical candidate)

Closed Loop Obstruction

• In general, considered a surgical emergency

• Commonly due to adhesions. Occurs when two points along the small bowel are obstructed at the same junction, causing necrosis and edema of the internal segment

• May look like a gasless abdomen on plain films. CT usually diagnostic and may show ground glass haziness in mid-abdomen, displacement of adjacent bowel, dilated clumps of edematous bowel, or classic U or C signs (pathognomonic)

Constipation

First-Line Medications

• Bisacodyl (Dulcolax) 10 mg orally daily or 10 mg per rectum daily

• Docusate sodium (Colace) 100 mg orally twice daily

• Mineral oil 15–45 mL/day

• Cascara 325 mg orally nightly

Second-Line/More Aggressive Medications

• Polyethylene glycol (MiraLax) 240–720 mL/day

• Lactulose 15–30 mL twice daily

• Sorbitol 120 mL of 25% solution daily

• Glycerin 3 g per rectum daily or 5–15 mL enemas

Remember: All patients on around-the-clock opiates should be on a bowel regimen...