1. Healthcare

Obstrucción intestinal maligna.
Dra. Karol Villalobos Garita
Especialista Medicina Paliativa UCR
Colegio de Médicos Febrero 2015
Introducción+
Definición+
Epidemiología+
Fisiopatología+
Clínica+y+Diagnós:co+
Tratamiento+
Conclusiones+
Presentación+Protocolo+
Introducción:
Hui D, De La Cruz M, Mori M, Parsons HA, Kwon JH, Torres-Vigil I, et al. Concepts and definitions for “supportive care,” “best supportive care,” “palliative care,” and
“hospice care” in the published literature, dictionaries, and textbooks. Support Care Cancer. 2013 Mar;21(3):659–85.
Movimiento Hospice: 1967
Hui D, De La Cruz M, Mori M, Parsons HA, Kwon JH, Torres-Vigil I, et al. Concepts and definitions for “supportive care,” “best supportive care,” “palliative care,” and
“hospice care” in the published literature, dictionaries, and textbooks. Support Care Cancer. 2013 Mar;21(3):659–85.
1975: Dr. Baulfor Mount
Cuidados paliativos
Hui D, De La Cruz M, Mori M, Parsons HA, Kwon JH, Torres-Vigil I, et al. Concepts and definitions for “supportive care,” “best supportive care,” “palliative care,” and
“hospice care” in the published literature, dictionaries, and textbooks. Support Care Cancer. 2013 Mar;21(3):659–85.
Década de los 80:
•
Consagró como especialidad,
•
Joven,
•
Continua evolucionando,
•
Moldear de acuerdo a las necesidades del pte y medicina moderna,
•
Poca evidencia científica, pocos estudios
•
Población frágil,
•
Protocolos que esxisten son basados en la experiencia,
J. Barbero, L. Díaz. Diez cuestiones inquietantes en cuidados paliativos. Sist Sanit Navar. 2007;30(3):71–86.
Desde la época de los pioneros…
Per spective
From pioneer days
to implementation:
lessons to be learnt
Mary Baines
worked for many
years alongside
Cicely Saunders at
St Christopher’s
Hospice; she was
one of the
founders of the
first UK palliative
home care service
Mary Baines reflects on the pioneering days of
palliative care, when she worked with Cicely Saunders at
St Christopher’s Hospice, in an article reproducing the
talk she gave in Lisbon last May at the 12th Congress
I
want to start by showing you this
photograph of Cicely Saunders, and I am
grateful to Avril Jackson, previously of the
Hospice Information Service,* for it. I like it
because of her smile and because it shows her
COURTESY OF LUKAS RADBRUCH
of the European Association for Palliative Care
Cicely Saunders
in 2001, four
years before
her death
Medicine and countless other publications, but
there is so much more to be learnt, not only
on symptom control but on all the other
aspects of palliative care.
Total pain
of life. The physical com
treatment with approp
regularly. Helping the e
components of pain in
treating anxiety and de
present, and spending
families, encouraging t
questions, and giving k
answers. Spiritual pain
about the past or a fear
death. It was explored w
admission by asking ab
not) of faith, so that sp
be addressed.
Time will not allow m
dimensions of total pai
the pioneer days but I w
One important early
Professor John Hinton
experience of care of pa
radiotherapy ward of a
those who were receivi
as an inpatient or at ho
at levels of anxiety and
Perhaps the best kno
the work and writings o
on bereavement. He ha
before St Christopher’s
invited him to start a b
from the beginning. Co
assessment card to be fi
the staff member who k
This gave details of the
thought to be most affe
Those who scored high
by a specially trained b
The effectiveness of t
the first in palliative ca
1981 and it is considere
most important piece o
bereavement support r
‘high-risk’ group to abo
group – a major reducti
I said that the regular giving of drugs to
EUROPEAN JOURNAL
OF PALLIATIVE CARE, 2011; 18(5)
control pain was the most important advance
in end-of-life care, but close to it – or even
1990: Organización Mundial de la Salud.
•
Definió: “Cuidado total activo de los pacientes cuya
enfermedad no responde a tratamiento curativo. El
control del dolor y de otros síntomas y de problemas
psicológicos, sociales y espirituales es primordial”.
Alivio del dolor y tratamiento paliativo en el cáncer. Ginebra: Organización mundial de la salud; 1990.
Obstrucción Intestinal Maligna:
Obstrucción Intestinal Maligna:
Se define usando los siguientes criterios: !
•!La evidencia clínica de obstrucción intestinal (historia / examen
físico/ radiológico),!
•!La obstrucción distal del ligamento de Treitz, !
•!Presencia de un cáncer primario intra-abdominal con enfermedad
no curable,!
•
Cáncer extra-abdominal con clara enfermedad intraperitoneal
Anthony T, Baron T, Mercadante S, Green S, Chi D, Cunningham J, et al. Report of the Clinical Protocol Committee: Development of Randomized Trials for Malignant Bowel Obstruction. J Pain Symptom Manage. 2007 Jul;34(1):S49–59. Epidemiología:
•
•
Más frecuentemente:
•
Cáncer colorectal: 4.4-24%
•
Cáncer ginecológicos: 5.5-42%
Cáncer de mama, pulmón y melanoma:
•
•
Extra-abdominales: 3-15%
Causas benignas: 10-48%
Ripamonti, Carla, Mercadante, Sebastiano. How to use Octreotido for Malignant Bowel Obstruction. J Support Oncol. 2004 Aug;2(4):357–64
!
Ripamonti, C. SM. Pathophysiology and management of malignant bowel obstruction. Oxford Textbook of palliative Medicine. 4th ed. New York: Oxford University Press; 2010. p. 850–63. Epidemiología:
•
Pronóstico es pobre.
•
Sobrevida de 3 meses.
•
Predictores de pobre pronóstico:
•
Estado nutricional
•
Ascitis
•
Carga tumoral
•
Tratamiento previo quimioterapia/radioterapia
Laval G, Arvieux C, Stefani L, Villard M-­‐L, Mestrallet J-­‐P, Cardin N. Protocol for the Treatment of Malignant Inoperable Bowel Obstruction: A Prospective Study of 80 Cases at Grenoble University Hospital Center. J Pain Symptom Manage. 2006 Fisiopatología:
Completa
Incompleta
33%
Ambos
20%
61%
Crisis suboclusivas
1 o múltiple niveles
80% presentan múltiples
niveles
65% carcinomatosis intestinal
Tuca A, Guell E, Martinez-­‐Losada E, Codorniu N. Malignant bowel obstruction in advanced cancer patients: epidemiology, management, and factors in`luencing spontaneous resolution. Cancer Manag Res. 2012 Jun;159.
Fisiopatología:
Obstrucción Intestinal Maligna
Secreción(
Distensión intestinal:
Obstrucción
mecánica:
acumulación
de fluidos y gases
Hiperac/vidad(
motora(
Aumento de las
peristálsis yo
presión
Obstrucción
funcional
ileo
endoluminal.
adinámico:
Respuesta inflamatoria intestinal:
prostaglandinas, PIV, mediadores
Infiltración tumoral
músculos
nociceptivos
Distensión(
Ciclo vicioso
nervios, (carcinomatosis
Oclusión
Hiperemiaextrínseca,
y edema de pared
intestinal
Oclusión intraluminal,
oclusión intramural,
y
peritoneal)
Cambios en la pared intestinal:
aumento de secreción
endoluminal de H2O,
Neuropatía
paraneoplásica,
Na+, Cl
Pseudo-obstrucción intestinal
crónica,
Pseudo-obstrucción
paraneoplásica
Dolor cólico y continuo
Secreción(
Nauseas y vómitos
Vómito fecaloide: Contaminación bacteriana por retención contenido intestinal
Pérdida de agua y electrolitos
Deteriori general del estado metabólico y hemodinámico
Elevación diafragmática: ventilación restrictiva
Tuca A, Guell E, Martinez-­‐Losada E, Codorniu N. Malignant bowel obstruction in advanced cancer patients: epidemiology, management, and factors in`luencing spontaneous resolution. Cancer Manag Res. 2012 Jun;159.
Clínica y Diagnóstico:
Síntomas comunes en ptes con
cancer con obstrucción intestinal
Vómitos!
Historia clínica y examen
Nauseas!
físico!
Dolor tipo cólico!
Nivel de obstrucción!
Dolor continuo!
Progresión
Sequedad boca!
Estreñimiento !
Oxford textbook of Palliative Medicine, 4th edition
Principles and practice of palliative care and supportive oncology, 4th edition
Diarrea por rebalsamiento
Diagnóstico
Radiológico:
•
•
Radiografía de abdomen de pie
y acostado.
!
Tomografía axial computarizado
de abdomen.
Soriano A, Davis MP. Malignant bowel obstruction: Individualized treatment near the end of life. Cleve Clin J Med. 2011 Mar 1;78(3):197–206. Adriana Dela Valle, Mijal Wolaj, David Santos, Fatima Mesa, Adriana Treglia. Manejo terapéutico actual de la oclusión intestinal maligna no quirúrgica. Rev Médica Urug. 2012;2(28):108–14. Patrice Taourel, Jean Fabre, Jean Pradel, Eric J. Seneterre, Alec J. Megibow, Jean-­‐M. Bruel. Value of CT in the diagnosis and management of patients with suspected acute small-­‐bowel obstruction. Am
Radiol. 1995 Nov;(165):1187–92. David Frager, Steven W. Medwid, Jeanne W, Baer, Bruce Mollinelli, Marvin Friedman. CT of small-­‐bowel obstruction: Value in establishing the diagnosis and determining the degree and cause. Am
Radiol. 1994 Jan;162:37–41. Extensión de la enfermedad
Tratamiento:
Pronóstico global
Comorbilidades asociadas
Estado funcional
Quirúrgico
No Quirúrgico
Tuca A, Guell E, Martinez-­‐Losada E, Codorniu N. Malignant bowel obstruction in advanced cancer patients: epidemiology, management, and factors in`luencing spontaneous resolution. Cancer Manag Res. 2012 Jun;159.
Tratamiento quirúrgico:
Cirugía paliativa
Objetivo principal: restablecer la
permeabilidad digestiva.
Buen estado general
único nivel obstrucción
Progresión lenta cáncer
Expectativa > 6 meses
Soriano A, Davis MP. Malignant bowel obstruction: Individualized treatment near the end of life. Cleve Clin J Med. 2011 Mar 1;78(3):197–206. Krouse RS. Surgical management of malignant bowel obstruction. Surg Oncol Clin N Am. 2004 Jul;13(3):479–90. Tratamiento quirúrgico:
Mortalidad a los 30 días: 25%
Morbilidad posquirúrgica 50%
Reobstrucción 48%
Sobrevida de 7 meses
Complicaciones quirúrgicas
Infección de la herida
Dehiscencia de herida
Absceso peritoneal
Fístula enterocutánea
Sangrado gastrointestinal
Ileo
Reobstrucción
Infarto del miocardio
Neumonía
Trombosis Venosa Profunda
Tromboembolismo pulmonar
Krouse RS. Surgical management of malignant bowel obstruction. Surg Oncol Clin N Am. 2004 Jul;13(3):479–90. Tratamiento quirúrgico:
Contraindicaciones:
Absolutas:!
Negativa del paciente!
Obstrucción funcional!
Ascitis!
Obstrucción múltiples sitios
Relativas:!
Estado funcional pobre!
> 65 años con caquexia!
Albúmina < 2,5 mg/dl!
Cancer metastásico con pobre control de
síntomas!
Carcinomatosis difusa!
Pérdida de peso > 9 kg!
Radioterapia previa abdomen y pelvis
Canadian Family Physician • Le Médecin de famille canadien | Vol 58: June • Juin 2012
NIH-PA Author Manuscript
Tratamiento quirúrgico:
NIH Public Access
Author Manuscript
Surgery. Author manuscript; available in PMC 2013 October 07.
Published in final edited form as:
Surgery. 2012 October ; 152(4): 747–757. doi:10.1016/j.surg.2012.07.009.
NIH-PA Author Manuscript
A scoring system for the prognosis and treatment of malignant
bowel obstruction
Jon C. Henry, MDa, Severin Pouly, MDa, Rachael Sullivan, MDa, Suhail Sharif, MDa, Dori
Klemanski, CNPa, Sherif Abdel-Misih, MDa, Nicole Arradaza, MSb, David Jarjoura, PhDb,
Carl Schmidt, MDa, and Mark Bloomston, MDa
Fig 1.
Kaplan–Meier overall survival curves of surgical versus nonsurgical therapy for the en
aDivision of Surgical Oncology, The Ohio State University College
of Medicine, Columbus, OH
bDivision
cohort of 523 patients (P < .001).
of Biostatistics, The Ohio State University College of Medicine, Columbus, OH
Abstract
Revisión
de 523 pacientes
OIMis a common result of end-stage abdominal cancer
Background—Malignant
bowel obstruction
that is a treatment dilemma for many physicians. Little has been reported predicting outcomes or
determining the role of surgical intervention. We sought to review our experience with surgical
Ingesta
oral
and nonsurgical management of malignant bowel obstruction
to identify
predictors of 30-day
mortality and of who would most likely benefit from surgical intervention.
2000 Y 2007
NIH-PA Author
Mortalidad 30 días
Methods—A chart review of 523 patients treated between 2000 and 2007 with malignant bowel
Sobrevida
obstruction were evaluated for factors present at admission to determine return to oral intake, 30day mortality, and overall survival. Propensity score matching was used to homogenize patients
treated with and without surgery to identify those who would benefit most from operative
or Manuscript
Nomograma de mortalidad 30 días:
Hallazgos Radiológicos:!
!
Carcinomatosis
Ascitis
Obstrucción Intestinal
completa
Hallazgos de laboratorio:!
NIH-PA Author Manuscript
!
Hipoalbuminemia
Leucocitosis
!
1 punto
1 punto
1 punto
!
1 punto
1 punto
Puntaje de 0-5, permite la predicción de
mortalidad 30 días
Fig 2.
(A) Nomogram to estimate 30-day mortality for patients presenting with malignant
obstructions independent of therapy. One point was assigned for each of the 5 variab
The distribution of 523 patients with malignant bowel obstruction for each number o
factors contributing to 30-day mortality. The blue portion of the bar represents the n
of patients alive at 30 days and the red represents the number of patients who were d
! The percentage above each bar is the percentage !dead at 30 days. (Color ve
30 days.
Carcinomatosis
1 punto
figure is available online.)
Nomograma beneficio de cirugía:
NIH-PA Autho
NIH Public Access
Author Manuscript
Surgery. Author manuscript; available in PMC 2013
Leucocitosis
1 punto
Albúmina normal
1 punto
Cáncer no ginecológico
1 punto
Score va de 0-4, el puntaje
asignado a cada paciente
permite
October
07. la predicción del
beneficio de la cirugía
Published in final edited form as:
Surgery. 2012 October ; 152(4): 747–757. doi:10.1016/j.surg.2012.07.009.
Aplicar el nomograma de mortalidad
30 días
Puntaje 4 ó 5
Manejo
conservador
Qué quiere el paciente
Puntaje 0-3
Obstrucción Intestinal maligna
completa?
NO
Si
Aplicar el nomograma de beneficio
de cirugía
Se debe de
considerar cirugía
Puntaje de 0-1
Puntaje 2
Puntaje 3-4
Se debe de
considerar cirugía
Considera cirugía
según el caso
Manejo
conservador
NIH Public Access
Author Manuscript
Surgery. Author manuscript; available in PMC 2013 October 07.
Published in final edited form as:
Surgery. 2012 October ; 152(4): 747–757. doi:10.1016/j.surg.2012.07.009.
Que pasa cuando la cirugía No es posible???
Pe r sp e ctive
COURTESY OF LUKAS RADBRUCH
Mary Baines
worked for many
years alongside
Cicely Saunders at
St Christopher’s
Hospice; she was
one of the
founders of the
first UK palliative
home care service
of life. The physical component usually needs
treatment with appropriate drugs, given
regularly. Helping the emotional and social
components of pain involves recognising and
treating anxiety and depression when they are
present, and spending time with patients and
families, encouraging them to talk and ask
questions, and giving kind but truthful
answers. Spiritual pain may be due to guilt
about the past or a fear of what happens after
death. It was explored with all patients on
admission by asking about the importance (or
not) of faith, so that spiritual anxieties could
be addressed.
Time will not allow me to mention all the
dimensions of total pain that were studied in
the pioneer days but I will highlight just two.
One important early study conducted by
Professor John Hinton compared the
experience of care of patients in the
radiotherapy ward of a teaching hospital with
those who were receiving hospice care either
as an inpatient or at home, looking especially
at levels of anxiety and depression.6
Perhaps the best known of early studies are
the work and writings of Colin Murray Parkes
on bereavement. He had met Cicely Saunders
before St Christopher’s opened and she
invited him to start a bereavement service
from the beginning. Colin developed an
assessment card to be filled in after death by
the staff member who knew the family best.
This gave details of the ‘key person’ – the one
thought to be most affected by the death.
Those who scored high were visited at home
Baines M, Oliver DJ, Carter RL. Medical management of intestinal obstruction in patients with advanced malignant disease. A clinical and pathological study. Lancet. 1985 Nov 2;2(8462):990–3.
Medicine and countless other publications, but
Sonda Nasogástrica:
Objetivo: descomprimir la cámara gástrica, reduciendo vómitos
Permite tiempo necesario para que tratamiento médico funcione
> 48 horas
Uso crónico:
disconformidad física, pobre estética, limita actividades diarias
Complicaciones:
Mayor riesgo de compilaciones, necrosis, úlceras y hemorragias
nasales, erosiones esofágicas y gástricas e infecciones como
sinusitis y otitis
Meyer L, Pothuri B. Decompresive Percutaneous Gastrostomy Tube Use in Gynecologic Malignancies. Curr Treat Options Oncol. 2006;7:111–20. Fonseca AL, Schuster KM, Maung AA, Kaplan LJ, Davis KA. Routine nasogastric decompression in small bowel obstruction: is it really necessary? Am Surg. 2013 Apr;79(4):422–8. Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc. 1981 Feb;27(1):9–11. Es realmente necesaria?
424
THE AMERICAN SURGEON
April 2013
Vol. 79
TABLE 1. Characteristics of Study Patients (n = 290)
NGT Decompression
No NGT Decompression
P Value
Characteristic
(n = 235)
(n = 55)
(OR, 95% CI)
Mean age
58.71 (± 19.58) years
54.96 (± 16.74) years
0.268
Gender
Male = 95 (40.43%)
Male = 22 (40%)
0.683
Comorbidities
Hypertension
167 (71.06%)
39 (70.90%)
0.847
Hyperlipidemia
137 (58.30%)
29 (52.73%)
0.412
Diabetes
110(46.81%)
16 (29.09%)
0.022(2.09, 1.10-3.69)
Coronary artery disease
67 (28.51%)
10(18.18%)
0.267
Atrial fibrillation
21 (8.93%)
2 (3.64%)
0.387
Immunosuppression
24 (10.21%)
3 (5.45%)
0.732
Chronic obstructive
37 (15.74%)
5 (9.09%)
0.329
pulmonary disease
Congestive cardiac failure
20(8.51%)
6 (10.91%)
0.578
Peptic ulcer disease
17 (7.23%)
3 (5.45%)
1.000
DVT/PE
16 (6.81%)
1 (1.82%)
0.474
Chronic renal failure
13 (5.53%)
2 (3.64%)
0.644
Prior surgical intervention
211 (89.79%)
48 (87.27%)
0.482
History of prior small bowel
94 (40%)
24 (43.64%)
0.758
obstruction
Current abdominal malignancy
37 (15.74%)
8 (14.55%)
0.939
Presenting clinical features
Nausea
220 (93.62%)
48 (87.27%)
0.087
Vomiting
182(77.45%)
37 (67.27%)
0.099
Abdominal distension
204(86.81%)
53 (96.36%)
0.045 (0.25, 0.06-1.07)
Tympany
194 (82.55%)
50 (90.91%)
0.035 (0.26, 0.09-0.98)
Abdominal pain
220 (93.62%)
54(98.18%)
0.132
Abdominal tenderness
206 (87.66%)
47 (85.45%)
0.572
Tachycardia
32 (13.62%)
3 (5.45%)
0.112
Hypotension
9 (3.83%)
0 (0%)
0.373
Fever
3 (1.28%)
1 (1.82%)
0.556
Peritonitis
3 (1.28%)
0 (0%)
0.556
NGT, nasogastric tube; OR, odds ratio; CI, confidence interval; DVT/PE, deep vein thrombosis/pulmonary embolus.
Hospital Yale New Haven
enero 2005-junio 2010
días de resolución,
las complicaciones asociadas,
la estadía hospitalaria y disposición
290 pacientes
190 manejo conservador
tympany, air-fluid levels, and dilated loops on abdominal radiographs and free fluid on CT scan
(Tables 3 and 4).
Univariate analysis
NGT placement or drainage volume was also not
Diabetes
2.09
1.10-3.69 0.022
associated with success of nonoperative management
Abdominal
0.25
0.06-1.07 0.045
distension
and avoidance of surgery. Fighty-seven patients in
Tympany
0.29
0.09-0.98 0.035
the cohort of 235 patients who received nasogastric
CT imaging
3.33
1.54-7.21 0.011
(NG) decompression required operative intervention,
CT with no
1.20
1.13-1.28 0.011
whereas
13 patients out of the 55 patients who did
colonie air
CT
gastric
0.26
vs
0.39
L
0.043
not Treceive
NG
required operative
inMeyer L, Pothuri B. Decompresive Percutaneous Gastrostomy ube Use in Gdecompression
ynecologic Malignancies. Curr Treat Options Oncol. 2006;7:111–20. volume
tervention
(P
=
0.08).
Fonseca A
L, S
chuster K
M, M
aung A
A, K
aplan L
J, D
avis K
A. R
outine n
asogastric d
ecompression i
n s
mall b
owel o
bstruction: is it really necessary? Am Surg. 2013 Apr;79(4):422–8. Multivariate
The
average
number
of
days
to
resolution
was
Ponsky analysis
JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc. 1981 Feb;27(1):9–11. 3.19 days (SD ± 3.15). The average hospital length of
Diabetes
2.60
1.06-6.33 0.036
2. Factors Associated with NGT Placement
Characteristic
Odds Ratio
95% CI P Value
TABLE
68 pacientes no se presentaron con vómitos. sin embargo se
colocó la SNG
Indicaciones SNG:
Distensión abdominal importante,
Vómitos intratables
No está indicado:
Rutina,
Uso crónico,
Ni en pacientes terminales.
Meyer L, Pothuri B. Decompresive Percutaneous Gastrostomy Tube Use in Gynecologic Malignancies. Curr Treat Options Oncol. 2006;7:111–20. Fonseca AL, Schuster KM, Maung AA, Kaplan LJ, Davis KA. Routine nasogastric decompression in small bowel obstruction: is it really necessary? Am Surg. 2013 Apr;79(4):422–8. Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc. 1981 Feb;27(1):9–11. Sonda Rectal?????
NO ESTA INDICADO
Gastrostomía percutánea de descarga:
Percutaneous Endoscopic Gastrostomy
Gastrointestinal Decompression
MICHAEL W. L. GAUDERER, M.D., F.A.C.S.
STELLATO AND GAUDERER
THOMAS A. STELLATO, M.D., F.A.C.S.
for
Ann. Surg
*
February 1987
From the Department of Surgery, Case Western Reserve
From September
1980 to of
April
1986, 185with
percutaneous
PEG forendoDecompression
Patients
Presentation
TABLE 1. Clinical
scopic gastrostomies were performed at University Hospitals of
University, University Hospitals of Cleveland,
Gastrostomía percutánea de descarga:
INDICACION:
Descompresión gástrica de forma crónica.
Método de colocación:
Endoscópico, Ultrasonografía, fluoroscopía o TAC
Contraindicaciones relativas:
Ascitis maligna, carcinomatosis peritoneal y tumores gástricos
Complicaciones:
Neumoperitoneo, perforación de intestino, fístula gastrocutánea,
hemorragia secundaria a laceración hepática, sangrado pared intestinal,
infección de herida, fuga periostomal, sangrado gastrointestinal,
obstrucción del tubo y expulsión.
Campagnutta E, Cannizzaro R. Percutaneous endoscopic gastrostomy (PEG) in palliative treatment of non-­‐operable intestinal obstruction due to gynecologic cancer: a review. Eur J Gynaecol Oncol. 2000;21(4):397–402. Shaw C, Bassett RL, Fox PS, Schmeler KM, Overman MJ, Wallace MJ, et al. Palliative Venting Gastrostomy in Patients with Malignant Bowel Obstruction and Ascites. Ann Surg Oncol. 2013 Feb;20(2):497–505. Stents endoscópicos:
Alternativa:
Unica obstrucción intestinal
No candidatos a la cirugía, Expectativa Corta de vida,
Pobre control de síntomas,
Rehusen a la cirugía.
Aadam AA, Martin JA. Enteral Stents in Malignant Bowel Obstruction. Gastrointest Endosc Clin N Am. 2013 Jan;23(1):153–64. Jeurnink SM, van Eijck CH, Steyerberg EW, Kuipers EJ, Siersema PD. Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. BMC Gastroenterol. 2007;7(1):18. Analgésicos:!
Escalera analgésica OMS
Opioides Fuertes
Dolor continuo
•
•
•
Anticolinérgicos:!
Butilbromuro de escopolamina
Hidrobromuro de escopolamina
RUTAS DE ADMINISTRACION:!
Infusión continua subcutánea
Infusión continua intravenosa
Transdérmica
Dolor tipo cólico
Agentes Antisecretores:!
Anticolinérgicos:!
• Butilbromuro de escopolamina (40-120 mg/día)
• Hidrobromuro de escopolamina (0.8-2.0 mg/día)
• Glicopirrolato (0,1- 0,2 mg tid subcutáneo o intravenoso)
!
y/o
Tratamiento
Farmacológico:
Análogos de somatostatin:!
•
Octreótido 0,2-0,9 mg/día infusión continua subcutánea o
intravenosa.
Nauseas y vómitos
Antieméticos:!
Metoclopramida (usar solo si la obstrucción es parcial y que se
presente con dolor tipo cólico)
!
Neurolépticos:!
• Haloperidol (5-15 mg/día infusión continua SC o IV)
• Metotrimeprazina (50-150 mg/día)
• Proclorperazina (25-75 mg/día vía rectal)*
• Clorpromazina (50-100 mg/8 h rectal o subcutáneo)*
!
Antihistamínicos:!
• Ciclizina (50-100 mg/día SC o rectal)
• Dimenhidrinato (50-100 mg/día SC)
Clinical Note
Jpn J Clin Oncol 2010;40(8)739– 745
doi:10.1093/jjco/hyq048
Advance Access Publication 21 April 2010
Aggressive Pharmacological Treatment
for Reversing Malignant Bowel Obstruction
Multicenter Prospective Study on Efficacy and Safety of Octreotide
for Inoperable Malignant Bowel Obstruction
Takayuki Hisanaga 1, Takuya Shinjo 2, Tatsuya Morita 3, Nobuhisa Nakajima 4, Masayuki Ikenaga 5,
Masahito Tanimizu 6, Yoshiyuki Kizawa 7, Takami Maeno 7, Yasuo Shima 1 and Ichinosuke Hyodo 7,*
Sebastiano Mercadante, MD, Patrizia Ferrera, MD, Patrizia Villari, MD,
and Antonio Marrazzo, MD
1
Tsukuba Medical Center Hospital, Tsukuba, 2Shakaihoken Kobe Central Hospital, Kobe, 3Seirei Mikatahara
General Hospital, Shizuoka, 4Tenshi Hospital, Sapporo, 5Yodogawa Christian Hospital, Osaka, 6National Hospital
Organization Shikoku Cancer Center, Matsuyama and 7Division of Gastroenterology, Graduate School of
Comprehensive Human, Sciences, University of Tsukuba, Ibaraki-ken, Japan
Pain Relief and Palliative Care Unit (S.M., P.F., P.V.) and Oncologic Surgical Unit (A.M.),
La Maddalena Cancer Center, Palermo, Italy
*For reprints and all correspondence: Ichinosuke Hyodo, Division of Gastroenterology, Graduate School of
Comprehensive Human, Sciences, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba-shi, Ibaraki-ken 305-8575,
Japan. E-mail: [email protected]
502 Journal of Pain and Symptom Management
Received December 21, 2009; accepted March 22, 2010
Abstract
Early and intensive pharmacological treatment not only may reduce gastrointestinal
Support Care Cancer (2000) 8 : 188–191
symptoms
but also reverse malignant bowel
obstruction.
Fifteen consecutive advanced
ORIGINAL
ARTICLE
DOI
10.1007/s005209900092
cancer patients with inoperable bowel obstruction received a combination of drugs
including metoclopramide, octreotide, dexamethasone and an initial bolus of amidotrizoato.
Recovery of intestinal transit was reported within 1-5 days in fourteen patients, who
continued this treatment without presenting symptoms of bowel obstruction until death.
Sebastiano
Mercadante
This case series
establishes that the combination of propulsive and antisecretive agents can
Carla Ripamonti
act synergistically
to allow a fast recovery of bowel transit without inducing unpleasant
Alessandra
Casuccio
colic. ItZecca
suggests that the most important mechanism in these circumstances is functional
Ernesto
and can
be reversible, if an aggressive treatment is initiated early before fecal impaction
Liliana
Groff
and edema render bowel obstruction irreversible. J Pain Symptom Manage 2004;
28:412–416. ! 2004 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All
rights reserved.
Comparison of octreotide and hyoscine
butylbromide in controlling
gastrointestinal symptoms due to
malignant inoperable bowel obstruction
Vol. 33 No. 2 February 2007
Journal of Pain and Symptom Management
Key Words
Malignant bowel obstruction, metoclopramide, octreotide, dexamethasone, amidotrizoato
217
Vol. 3
Objective: The aim of this study was to evaluate the efficacy and safety of octreotide for
malignant bowel obstruction in a multicenter study.
Original
Article
Methods:
Terminally ill patients diagnosed with inoperable malignant bowel obstruction were
treated with octreotide 300 mg/day. The primary endpoint was the overall improvement rate of
subjective abdominal symptoms. The degrees of nausea, vomiting, abdominal pain, distension, anorexia, fatigue, thirst and overall quality of life were evaluated by the self-rating scores
selected from the MD Anderson Symptoms Inventory and Kurihara’s Face Scale.
Results: Forty-nine patients were enrolled in the study, and 46 patients received study treatment, including 17 gastric, 13 colorectal, 7 ovarian and other cancers. The median survival
time was 25 days. The number of vomiting episodes significantly correlated with the MD
Anderson Symptoms Inventory nausea and vomiting scores (P , 0.001) before octreotide
treatment. Of 43 patients evaluable for efficacy, the scores of all the MD Anderson Symptoms
Inventory items except abdominal pain and the number of vomiting episodes improved during
the first 4 days of octreotide treatment (P , 0.0062). The MD Anderson Symptoms Inventory
Guillemette
Laval,
MD, Catherine
PhD, Laetitia
Stefani,
MD,
scores were
decreased
in 59 – 72% Arvieux,
of patients,MD,
and overall
quality-of-life
scores
improved in
56%
of
patients.
No
serious
adverse
events
were
observed.
Marie-Laure Villard, MD, Jean-Phillippe Mestrallet, MD, and Nicolas Cardin, MD
high improvement
rate in (G.L.,
abdominal
symptoms
suggested
the efficacy
Unite´Conclusions:
de Recherche etThe
de Soutien
en Soins Palliatifs
M.-L.V.)
and Oncologie
Me´dicale
(L.S.), of
octreotide in terminally ill patients with malignant bowel obstruction.
Protocol for the Treatment of Malignant
Inoperable Bowel Obstruction:
A Prospective Study of 80 Cases
at Grenoble University Hospital Center
Departement de Cancerologie et d’Hematologie; and De´partement de Chirurgie Digestive et de l’Urgence
(C.A.,Key
J.-P.M.,
Le Centre
de Symptoms
Grenoble, Inventory
Grenoble, –France
words:N.C.),
malignant
bowel Hospitalier
obstruction Universitaire
– MD Anderson
octreotide –
subjective abdominal symptoms
Abstract
Support Care Cancer (2011) 19:431–433A prospective protocol for treatment of malignant inoperable bowel obstruction was
DOI 10.1007/s00520-010-1009-4
implemented at Grenoble University Hospital Center for 4 years. All 80 episodes of
INTRODUCTION
motility, andand
to promote
water and
electrolyte
obstruction resulted from peritoneal carcinomatosis
none could
expect
anotherabsorption
treatment(4).
The efficacy of octreotide in controlling abdominal sympMalignant bowel obstruction (MBO) associated with
SHORT COMMUNICATION
cure. The protocol comprised three successive
stages. Stage I included treatment for 5 days
toms of patients with MBO has been suggested in small proadvanced or recurrent cancers interferes with the intake of
Abstract In advanced cancer paafter (T3), and the mean daily
Published online: 5 October 1999
with
a
corticosteroid,
antiemetic,
anticholinergic,
andonanalgesic.
Stage
II provided
spective trials
the basis of
objective
parameters such as
food and causes abdominal symptoms (nausea, vomiting,
tients with inoperable bowel
ob- hasamounts
of fluids to
administered
i.v.
Q Springer-Verlag 2000
octreotide
been reported
be more
effeca somatostatin
analogue
if vomiting
After
3 days, Stage
IIIand
provided
ventingfrom
the number
of vomiting
episodes
drainagea volume
abdominal pain and
fullness). Quality
of life
(QoL) is persisted.
struction, the administration
of anor s.c.butylbromide.
during the period
study.impaired,gastrostomy.
1–3 ofseverely
a nasogastric
tubeobtained
(5 – 9), but
efficacy
of octreotide
and a nasogastric
tube forrelief
drainage
Obstruction
with issymptom
control was
by the
medical
treatment
in 29on
tive than
hyoscine
subjective
symptoms
has
been
unclear.
Therefore,
a
prospecoften
these
symptoms
even
in
palliative
tisecretive
and antiemetic drugs
Three patients dropped out
ofrequired
the to alleviate
Malignant bowel obstruction (MBO)
is a sericases and symptom control occurred alone in an additional 32 cases. Ten patients were
Previous
reports
have shown
that
these
tive study of octreotide therapy has been performed in
care (1treat– 3). Therefore, an effective drug therapy in terminhas
proved
to
be
effective
in
constudy
because
data
were
incomrelieved by venting gastrostomy. Symptompatients
controlwith
without
permanent nasogastric tube (NGT)
ous complication in advanced cancer patients,
MBO to investigate the improvement focusing
allytransit
ill patients4 is required.
ments
may
allow
a
recovery
of
bowel
trolling gastrointestinal symptoms
plete. Octreotide treatment The
in- somatostatinplacement
occurred
in
72
episodes
(90%).
Eight
patients
withThe
refractory
vomiting
on subjective symptoms.
correlation
betweenwere
subjective
analog, octreotide, has been shown to
and most commonly affects patients with abdomand
may
improve
the
local
condition
prior
to
obliged
to
continue
the
NGT
until
death.
Fifty-eight
obstruction
episodes
(73%)
wererelating to
and
objective
parameters,
differences
in
efficacy
suppress
secretion
of
digestive
enzymes
and
gastrointestinal
caused by bowel obstruction. How- duced a significantly rapid reduc-
Review Article
Medical Treatment for Inoperable Malignant
Bowel Obstruction: A Qualitative
Systematic Review
Introduction
Can malignant bowel obstruction in advanced cancer
patients be treated at home?
Sebastiano
Mercadante,
MD, Alessandra
Casuccio, BS,
Giampiero Porzio & Federica Aielli & Lucilla Verna &
inal
or pelvic
tumors. Conservative
management
controlled in 10 days or less. Median
time before gastrostomy was 17 days. Median survival
by preventing
theBrigida
pathological
ever, controlled studies surgery
concerning
tion in the number
of
daily& Ghazaleh
epi-alter-Shoja
# The Author (2010). Published by Oxford University Press. All rights reserved.
Galletti
e Razavi &
and
Salvatore
Mangione,
MD
was 31 days. This series suggests that a staged protocol for the treatment of inoperable
5 This
with a combination of antisecretivethe
drugs,
most analeffective antisecretive
sodes
of vomiting
andFicorella
intensity
of
observation
ations of bowel
obstruction.
Corrado
Pain Relief & Palliative Care Unit (S.Me.), La Maddalena Cancer Center; and Departments of
drug
are lacking.
of this that
nauseaand
compared
with
HB treat-not malignant bowel obstruction is highly effective in relieving symptoms. A subgroup experiences
gesics,
and antiemetics proved to be
effective
in The aim
suggests
early
intensive
treatment
Anesthesiology, Intensive Care and Emergency Medicine (S.Me., S.Ma.), and Ophthalmology
(A.C.),
relief of obstruction using this approach. J Pain Symptom Manage 2006;31:502--512.
randomized controlled study
ment atgastrointestinal
the different timesymptoms,
intervals
controlling
gastrointestinal
only was
may reduce
University of Palermo,
Palermo, Italy symptoms in inoper! 2006 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
to determine
or
examined.
No relevant
changes
S.able
Mercadante,
M.D.Among
(Y)
patients.
the antisecretive
drugs,whether octreotide
but
also
reverse
functional
MBO,
allowing
a
Pain Relief and Palliative Care, SAMOT,
hyoscine butylbromide was the
were found inReceived:
dry mouth,
drowsi1 March
2010
September
Words2010 / Published online: 25 September 2010
clear
improvement
in
both
quality
of
life/ Accepted:
and 14Key
via Libertà 191, I-90143 Palermo, Italy
#
2010 levels
more effective antisecretive drug
ness and colickySpringer-Verlag
pain. Lower
e-mail: mercadsa6tin.it
survival. In a retrospective analysis (unpub- Malignant bowel obstruction, peritoneal carcinomatosis, palliative care, venting gastrostomy,
Soporte nutricional e hidratación:
Fan B-­‐G. Parenteral nutrition prolongs the survival of patients associated with malignant gastrointestinal obstruction. JPEN J Parenter Enteral Nutr. 2007 Dec;31(6):508–10. Bozzetti F, Cozzaglio L, Biganzoli E, Chiavenna G, De Cicco M, Donati D, et al. Quality of life and length of survival in advanced cancer patients on home parenteral nutrition. Clin Nutr Edinb Scotl. 2002 Aug;21(4):281–8.
Mercadante S, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. 2000 May;8(3):188–91. Burge FI. Dehydration symptoms of palliative care cancer patients. J Pain Symptom Manage. 1993 Oct;8(7):454–64. Entidad devastadora
Cirugía no es posible
Evolución de la medicina paliativa
Conclusiones:
Individualizar casos : manejo
conservador heterogéneo
SIEMPRE hay alternativa
Gastrostomía de descarga
Manejo de equipo interdisciplinar
Síntomas de obstrucción
intestinal
en paciente con cancer
Considerar
gastrostomía
descarga
Gastroenterología
Oncología
Persistencia de sínto
Ginecología oncológica
Equipo de
cuidados
paliativos
Cirugía oncológica
Medicina Paliativa
Psico-oncología
Candidato a cirugía
Se debe de tomar en cu
Soporte nutricional
Contraindicaciones
Absolutas
Negativa del paciente
Obstrucción funcional
Múltiples niveles de oclusión
Ascitis refractaria
Evaluación clínica:
Historia síntomas
Evaluación radiológica:
Diagnóstico y causa,
Única o múltiple
Parcial o completa
Factores de paciente:
Edad,
Estado funcional,
Toma decisiones:
Identificar causa,
Estadio del cáncer: tratamiento previo,
Mecánica o funcional,
Opciones de tratamiento,
Evaluar intervenciones para aliviar síntomas
Comorbilidades
Co
Maln
H
Carcin
M
Enfermedad m
Factores de Técnicos:
Estado
Insufici
Previa r
Intervención: radiológica, endoscópica,
Laparoscopía/Laparotomía,
Anestesia,
Riesgo de complicaciones,
Contraindicaciones.
Nomograma predecir mortalidad
30 días:
Hallazgos Radiológicos:
Decidir el manejo con paciente y familia:
Carcinomatosis
Ascitis
Obstrucción Intestinal completa
Metas: calidad de vida,
Mortalidad en 30 días,
Expectativas del tratamiento,
Hallazgos de laboratorio:
Riesgos y beneficios
Resolución
Manejo Farmacológico
síntomas
Hipoalbuminemia
Leucocitosis
Puntaje de 0-5
4-5 Manejo conservador
0-3
Aplicar nomograma de
beneficio de cirugía
Persistencia de
síntomas
67
Colocar SNG
Cirugía:
Continuar manejo
síntomas
médico
Contraindicaciones,
gastrostomía de
descarga
1 punto
1 punto
1 punto
1 punto
Score va de 0-4, el puntaje asignado a cada paciente
permite la predicción del beneficio de la cirugía
Mortalidad 30 diás,
Beneficio de cirugía
Considerar
1 punto
1 punto
Nomograma para estimar posible
beneficio de cirugía:
Carcinomatosis
Leucocitosis
Albúmina normal
Cáncer no ginecológico
Candidato a
Resolución de
1 punto
1 punto
1 punto
Manejo farmacológico
hasta cirugía
Algoritmo para el uso de los dos nomogramas anteriores:
Pacientes que serán sometidos a cirugía por OIM,
manejo farmacológico preoperatorio.
Octreotido 100 ug cada 8 horas IV hasta cirugía
Hidratación IV
Sonda nasogástrica
Antibióticos
Mantener octreotido primeras 24 a 48 horas postoperatorio.
69
Manejo Farmacológico:
Etapa 1: Día 1 al día 3
1.
2.
3.
4.
5.
6.
Nada vía oral + hidratación 1-1,5 L IV o SC
Tratamiento sintomático se adaptará a cada caso
Antieméticos:
o Neurolépticos: Haldol 5-15 mg por día
o Metoclopramida contraindicado en obstrucción completa
Anticolinérgicos/antisecretor:
o Pueden considerarse como primera línea, según disponibilidad
o Buscapina 40-120 mg/día
Análogo de somatostatina
o Puede ser considerado como primera línea, según disponibilidad
o Octreótido 300-900 ug por día
Esteroides:ciclos cortos de 5-10 días, IV o SC
o Dexametasona: 4 mg cada 8 horas IV o SC
Analgésicos:Según escala analgésica de la OMS
Sonda Nasogástrica:
o Distensión gástrica importante
> 2 vómitos por día
o Vómitos abundantes
Etapa 2: Reevaluación en día 4
Si la obstrucción resuelve:
o Esteroides y anticolinérgicos ir disminuyendo dosis hasta suspender.
4.
5.
6.
o Puede ser considerado como primera línea, según disponibilidad
o Octreótido 300-900 ug por día
Esteroides:ciclos cortos de 5-10 días, IV o SC
o Dexametasona: 4 mg cada 8 horas IV o SC
Analgésicos:Según escala analgésica de la OMS
Sonda Nasogástrica:
o Distensión gástrica importante
o Vómitos abundantes
Etapa 2: Reevaluación en día 4
Si la obstrucción resuelve:
o Esteroides y anticolinérgicos ir disminuyendo dosis hasta suspender.
o Esteroides ciclos cortos de 5-10 días
o Anticolinérgicos suspender dos días después de estar libre de síntomas.
Si la obstrucción no resuelve y persiste vómitos:
o Iniciar octreótido si no se había iniciado antes
o La meta es mantener al paciente con < 2 vómitos al día
Si el octreótido se uso de primera línea, se pasa a la etapa 3
Etapa 3: Reevaluación en día 7
o Anticolinérgicos suspender dos días después de estar libre de síntomas.
Si la obstrucción no resuelve y persiste vómitos:
o Iniciar octreótido si no se había iniciado antes
o La meta es mantener al paciente con < 2 vómitos al día
Si el octreótido se uso de primera línea, se pasa a la etapa 3
Etapa 3: Reevaluación en día 7
Colocar SNG si no se ha colocado
Preguntas…
“Nunca tengas dudas que un pequeño grupo
de ciudadanos comprometidos y responsables
puede cambiar el mundo. De hecho, eso es
una cosa que siempre ocurre”
– Margarita Mead
Muchas gracias!!!!!!
Amanecer Cerro Chirripó 13/feb/14