Arch Gynecol Obstet (1996) 258: 213–218

© Springer-Verlag 1996

Intestinal obstruction in patients

with advanced gynecological cancer
A study of 62 cases
C. Emmert 1, U. Schenker 2, U. Köhler 1
1
Department of Obstetrics and Gynecology, University of Leipzig,
Philipp-Rosenthal-Strasse 55, D-04103 Leipzig, Germany
2
Department of Surgery, University of Leipzig, Germany

Received: 15 March 1996 / Accepted: 26 April 1996

Abstract. In total, 62 cases with advanced gynecological malignancy were ana-

lyzed for the value of interventions for intestinal obstruction. 35 patients had an
ileostomy, 7 patients had other palliative surgical intervention and 20 patients were
managed conservatively. The median survival after surgical intervention was
7.7 months as against 1.3 months in conservatively treated patients. After surgery,
all patients were affected by severe complications due to the primary disease.
22 (52.3%) of surgically treated patients received further therapy. 45 out of 62 pa-
tients (77.4%) died of progressive cancer and 14 (22.6%) of ileus. Surgical inter-
vention had a positive effect on survival time, but only a marginal effect on life
quality.

Key words: Gynecological malignancy – Intestinal obstruction – Surgical inter-

vention – Ileostomy

Introduction

Intestinal obstruction is common in patients with advanced gynecological malig-

nancy. The value of surgical intervention is controversial because of the limited
life expectancy in such cases (Ripamonti 1994 a, Zoetmulder et al. 1994, Sun et al.
1994, Baines 1994, Ripamonti et al. 1993, Kauffmann et al. 1993). While surgery
must remain the primary treatment for malignant obstruction, there is also a group
of patients with advanced disease or poor general condition who are unfit for sur-
gery and receive only conservative management to relieve distressing symptoms
(Ripamonti et al. 1994 a). We analyzed gynecological cancer patients with intesti-
nal obstruction with special regard to the outcome of cases without surgical inter-
vention.

Correspondence to: C. Emmert

214 C. Emmert et al.

Material and methods

Our survey included 62 patients with advanced gynecological malignancy (30 ovarian carcino-
mas, 15 cervical carcinomas, 8 endometrial carcinomas, 3 vaginal carcinomas, two tubal carci-
nomas, one vulval carcinoma, one chorion epithelioma, one metastasing breast carcinoma and
one uterine leiomyosarcoma). The median age of the patients at first treatment for the primary
disease was 55.2 (31 – 76) years. 35 patients (56.5%) had an ileostomy and 7 patients (11.3%)
had other surgical interventions (exploratory laparotomy or enterostomy). 20 patients (32.2%)
had not surgery. The interval from first presentation of the intestinal obstruction to death ranged
from 0 – 101 months.

Table 1. Treatment of patients with advanced gynecological malignancy before occurrence of

intestinal obstruction (n = 62)

Ileostomy Other surgical Conservatively

(n = 35) intervention treated
(n = 7) (n = 20)

Surgery 3 2 3
Surgery/chemotherapy 15 2 6
Surgery/radiotherapy/Radiochemotherapy 10 2 8
Radiotherapy 1 1 3
No previous therapy 6

Table 2. General, surgical, urological and gynecological complications in patients with ad-
vanced gynecological malignancy after diagnosis and/or first treatment of intestinal obstruction
(n = 62)

Ileostomy Other surgical Conservatively

(n = 35) intervention treated
(n = 7) (n = 20)

General
Pain/opiate therapy 6 1
Thrombosis 4 2
Lymphedema 2
Pleural effusion 2
Pneumonia 1
Tumoranemia 1 1
Ascites 1
Surgical
Recurrent ileus 5
Further ileus 2 11
Intestinal bleeding 2
Rectovaginal fistula 1
Peritonitis 2
Urological
Hydronephrosis 7 1 2
Bladderbleeding 5
Nephrostomy 4
Vesicovaginal fistula 1
Recto-vesico-vaginal fistula 1
Gynecological
Vaginal bleeding 2
Intestinal obstruction in patients with advanced gynecological cancer 215

Results

The median interval from treatment for the primary cancer to intestinal obstruc-
tion was 23.9 (0 – 92) months. The treatment before proven intestinal obstruction
included surgery and chemotherapy in 15 of 35 patients with later ileostomy, and
6 of 20 patients later treated conservatively (Table 1). After diagnosis and/or first
treatment of the intestinal obstruction almost all patients were affected by severe
general, surgical, urological or gynecological problems caused by the primary dis-
ease (Table 2).
Complications associated with the ileostomy occured in 25.7% (Table 3). In-
testinal obstruction was recurrent in 7 of 35 cases. Further antineoplastic treatment
was received by 18 ileostomy patients, 2 patients who underwent other palliative
surgery for intestinal obstruction and by none of the conservatively treated patients
(Table 4). The cause of death was progressive cancer in 30 patients. 3 ileostomy
patients and 11 conservatively treated patients died of ileus (Table 5).

Table 3. Ileostomy complications in patients with advanced gynecological malignancy (n = 35)

Recurrent ileus (1 – 2 episodes) 5

Further ileus symptoms 2
Bleeding ex ileostomy 1
Intestinal prolapse via ileostomy 1

Table 4. Therapy of patients with advanced gynecological malignancy after diagnosis and/or
surgical treatment of intestinal obstruction (n = 62)

Ileostomy Other surgical Conservatively

(n = 35) intervention treated
(n = 7) (n = 20)

Surgery 1
Surgery/chemotherapy 1
Chemotherapy 12 2
Radiotherapy 4
Symptomatically 17 5 20

Table 5. Cause of death in patients with advanced gynecological malignancy and intestinal ob-
struction (n = 62)

Ileostomy patients Patients with Patients treated

(n = 35) other surgery conservatively
(n = 7) (n = 20)

Progressive cancer 30 6 7
Ileus 3 11
Pneumonia 1
Suicid 1
Cardiovascular failure 1
Peritonitis 2
216 C. Emmert et al.

Table 6. Survival time in patients with advanced gynecological malignancy and intestinal ob-
struction (n = 62)

Survival time Ileostomy patients Patients with Patients treated

(months) (n = 35) other surgery conservatively
(n = 7) (n = 20)

0–2 8 4 18
2–6 6 2 2
6 – 12 13 1
>12 8
Median (months) 11.8 3.7 1.3
Range (months) 0 – 101 1 – 11 0–3

The difference in median survival between ileostomy patients and patients with
other surgical interventions was 8.1 months, conservatively treated patients did not
survive for long (Table 6).

Discussion

The gynecologist manages more than 20% of women with intestinal obstruction
due to postoperative adhesions or malignancy (Stricker et al. 1994). Intestinal ob-
struction in advanced cancer patients may be caused by adhesions, focal malignant
deposit or diffuse carcinomatosis (Cox et al. 1993, Ripamonti et al. 1993). Intes-
tinal obstruction due to intraperitoneal adhesions is a frequent sequal of radical
hysterectomy, being significantly higher if concomitant radiotherapy is given
(Montz et al. 1994, Eifel et al. 1995). Its incidence is 4.2 – 20% in cervical cancer
treated with surgery plus irradiation (Perez et al. 1995, Monk et al. 1993) and
4.6 – 42% in cases of ovarian cancer (Fyles et al. 1995, Morton et al. 1994, Ripa-
monti et al. 1994 b). 23 of our 62 patients were treated previousely by surgery and
chemotherapy, 20 were managed by surgery and radiotherapy.
Surgery is required for intestinal obstruction after abdominal irradiation of ovar-
ian carcinoma in 2.6 – 5% (Fyles et al. 1992, Thomas et al. 1995) and in 8.6 – 14.3%
of patients treated by chemotherapy and radiotherapy (Fein et al. 1994, Whelan
et al. 1992). Ileus requiring surgery occurs in 3.2% of patients irradiated for cer-
vical cancer (Persson et al. 1992). Palliative surgery for intestinal obstruction in
advanced cancer patients inevitably has high mortality and morbidity (Baines
1994). Zoetmulder et al. (1994) suggested a classification of ovarian cancer cases
with intestinal obstruction into a favourable prognosis group (no previous treat-
ment or >6 months since last treatment; no ascites) and a poor prognosis group (<6
months since last treatment; ascites). Our results justify a more positive approach
towards surgery, because 18 of 35 (51.4%) ileostomy patients and 2 of 7 (28.6%)
patients with other surgical intervention could receive further antineoplastic treat-
ment (chemotherapy in 13 of 62 cases). Therefore, if conservatism fails, laparot-
omy should be undertaken in patients who are not terminally ill. 35 of 62 patients
received ileostomy and 7 patients underwent laparotomy with palliative gut resec-
tion and entero-enterostomy. The interval from evidence and/or first therapy of pri-
mary disease to intestinal obstruction in our study was about 23.9 (0 – 92) months.
Survival was prolonged in patients with ileostomy, but extremely poor in the con-
Intestinal obstruction in patients with advanced gynecological cancer 217

servatively treated patient group, where 11 of 20 of patients died of ileus. Sun et al.
(1995) reporting on patients with intestinal obstruction and advanced ovarian can-
cer found that 97.7% died of ileus and that the median survival time was 110 days.
Commonest complications of ileostomy are skin problems, intestinal obstruction,
retraction and parastomal herniation (Leong et al. 1994). In our study, 9 ileostomy
patients had stoma problems. The long-term risk of recurrent intestinal obstruc-
tion is diminished but not eliminated by surgery (Landercasper et al. 1993). Re-
current intestinal obstruction affected only 5 ileostomy patients during their mean
survival of 11.8 (0 – 101) months.
Terminal care focuses on nutritional support, pain control and symptomatic
management of intestinal obstruction (Kerr-Wilson et al. 1994, Mann 1994). Few
patients will benefit from a nasogastric tube or venting gastrostomy and fluids
given by intravenous infusion, but it can not cause resolution of the obstruction
and involves hospitalisation, immobility and discomfort (Baines 1994). Fainsinger
et al. (1994) reported good symptom control in terminally ill patients treated with
nasogastric tubes and medical means. Pharmacologic treatment for control of
colic, abdominal pain and vomiting is effective in the majority of patients (Baines
1994).
In summary, surgical intervention, especially ileostomy can be of value to re-
move life-threatening intestinal obstruction and to achieve longer survival with
possibility to receive a further antineoplastic therapy. However, an increased rate
of several other severe complications is the price that the patient may have to pay.

References
Baines MJ (1994) Management of intestinal obstruction in patients with advanced cancer. Ann
Acad Med Singapore 23: 178 – 182
Cox MR, Gunn IF, Eastman MC, Hunt RF, Heinz AW (1993) The operative ethiology and types
of adhesions causing small bowel obstruction. Aust N Z J Surg 63: 848 – 852
Eifel PJ, Levenback C, Wharton JT, Oswald MJ (1995) Time course and incidence of late com-
plications in patients treated with radiation therapy for FIGO stage IB carcinoma of the ute-
rine cervix. Int J Radiat Oncol Biol Phys 32: 1531 – 1534
Fainsinger RL, Spachynski K, Hanson J, Buera E (1994) Symptom control in terminally ill pa-
tients with malignant bowel obstruction (MBO). J Pain 9: 12 – 18
Fein DA, Morgan LS, Marcus RB, Mendenhall WM, Sombeck MD, Freman DE, Million RR
(1994) Stage III ovarian carcinoma: an analysis of treatment results and complications fol-
lowing hyperfractionted abdominopelvic irradiation for salvage. Int J Radiat Oncol Biol Phys
29: 169 – 176
Finan MA, Barton DP, Fiorica JV, Hoffman MS, Roberts WS, Gleeson N, Cavanagh D (1995)
Ileus following gynecologic surgery: management with water-soluble hyperosmolar radio-
contrast material. South Med J 88: 539 – 542
Fyles AW, Dembo AJ, Bush RS, Levin W, Manchul LA, Pringle JF, Rawlings GA, Sturgeon JF,
Thomas AW, Simm J (1992) Analysis of complications in patients treated with abdomino-
pelvic radiation therapy for ovarian cancer. Int J Radiat Oncol Biol Phys 22: 847 – 851
Kerr-Wilson R (1994) Terminal care of gynecological malignancy. Br J Hosp Med 51: 113 – 118
Mann WJ (1994) Diagnosis and management of epithelial cancer of the ovary. Am Fam Physi-
cian 49: 613 – 618
Monk BJ, Solh S, Johnson MT, Montz FJ (1993) Radical hysterectomy after pelvic irradiation
in patients with high risk cervical cancer or uterine sarcoma: morbidity and outcome. Eur J
Gynecol Oncol 14: 506 – 511
Montz FJ, Holschneider CH, Solh S, Schuricht LC, Monk BJ (1994) Small bowel obstruction
following radical hysterectomy: risk factors, incidence and operative findings. Gynecol
Oncol 53: 114 – 120
218 C. Emmert et al.

Morton G, Thomas GM (1994) Role of radiotherapy in the treatment of cancer of the ovary.
Semin Surg Oncol 10: 305 – 312
Leong AP, Londono-Schimmer EE, Phillips RK (1994) Life-table analysis of stomal complica-
tions following ileostomy. Br J Surg 81: 727 – 729
Perez CA, Grigsby PW, Camel HM, Galaktos AE, Mutch D, Lockett MA (1995) Irradiation alone
or in combination with surgery in stage I B, II A, and II B carcinoma of uterine cervix: update
of a nonrandomized comparison. Int J Radiat Oncol Biol Phys 31: 1007 – 1008
Persson H, Hedberg B, Angquist KA, Stendhal U (1992) Surgical management of intestinal com-
plications of radiotherapy for gynecological malignancies. Eur J Gynecol Oncol 13: 419 – 426
Ripamonti C (1994 a) Management of bowel obstruction in advanced cancer patients. J Pain
9: 193 – 200
Ripamonti C (1994 b) Management of bowel obstruction in advanced cancer. Curr Opin Oncol
6: 351 – 357
Ripamonti C, De-Conno F, Ventafridda V, Rossi B, Baines MJ (1993) Management of bowel ob-
struction in advanced and terminal cancer patients. Ann Oncol 4: 15 – 21
Stricker B, Blanco J, Fox HE (1994) The gynecologic contribution to intestinal obstruction in
females. J Am Coll Surg 178: 617 – 620
Sun X, Li X, Li H (1995) Management of intestinal obstruction in advanced ovarian cancer –
an analysis of 57 cases. Chung Hua Chung Liu Tsa Chin 17: 39 – 42
Tang E, Davis J, Silberman H (1995) Bowel obstruction in cancer patients. Arch Surg 130:
832 – 837
Thomas L, Pigneux J, Chauvergne J, Stockle E, Bussiers E, Chemin A, Toulouse C (1994) Eval-
uation of whole abdominal irradiation in ovarian carcinoma with a four orthogonal fields
technique. Int J Radiat Oncol Biol Phys 30: 1083 – 1090
Whelan TJ, Dembo AJ, Bush RS, Sturgeon JF, Fine S, Pringle JF, Rawlings GA, Thomas GM,
Simm J (1992) Complications of whole abdominal and pelvic radiotherapy following chemo-
therapy for advanced ovarian cancer. Int J Radiat Oncol Biol Phys 22: 853 – 858
Zoetmulder FA, Helmerhorst TJ, van-Coevorden F, Wolfs PE, Leyer JP, Hart AA (1994) Man-
agement of bowel obstruction in patients with advanced ovarian carcinoma. Eur J Cancer
30: 1625 – 1628