Malignant Bowel Obstruction: Evidence vs Pragmatism · In mechanical bowel obstruction: •...

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Malignant Bowel Obstruction: Evidence vs Pragmatism Simon Noble Marie Curie Professor of Supportive and Palliative Medicine Marie Curie Palliative Care Research Centre Cardiff University

Transcript of Malignant Bowel Obstruction: Evidence vs Pragmatism · In mechanical bowel obstruction: •...

Page 1: Malignant Bowel Obstruction: Evidence vs Pragmatism · In mechanical bowel obstruction: • ranitidine 150mg + dexamethasone 8mg + IV fluids + comfort PO fluids –if colic add HBB

Malignant Bowel Obstruction:

Evidence vs Pragmatism

Simon Noble

Marie Curie Professor of Supportive and Palliative Medicine

Marie Curie Palliative Care Research Centre

Cardiff University

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Aims

1. Philosophical rant about Pall Care and evidence based medicine

2. Review the published data on medical management of MBO

3. Consider practical approach to management of MBO

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Case 1

• 78 year old female

• Stage IV ovarian cancer

• Debulking

• “Adjuvant chemotherapy”

• Stormy course

• Febrile neutropenia

• Several episodes self resolving small bowel obstruction

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Case 1

• Progressive deterioration

• Admitted N and V

• CT scan confirms clinical suspicion of MBO

• NG free drainage/ IV fluids

• 3 weeks farting about

• Not fit enough for surgery

• Ondansetron ping pong

• Await oncological opinion

• “wait until you are a bit stronger”

• Refer palliative care

• Rapid deterioration with complex psychological components

• Died on usual 2 driver cocktail of octreotide and every antiemetic known to

man 4

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What's the worst symptom?

)

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The nausea without doubt. Sometimes I even

welcome being sick since I know it heralds a

period of time when I wont feel queasy for a

while. Being afraid to move incase the nausea

gets worse.

78 year old female

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Case 2

• 38 year old female

• 3 years ago presented with MBO

• Emergency laparotomy

• Chemotherapy

• Basingstoke: peritoneal stripping

• Chemo

• Recurrence after 6 months

• Palliative chemotherapy

• Complications: chemo break

• MBO

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Case 2

• Opts for optimising quality of life

• No further chemo

• Ryles tube

• Commenced TPN

• Excellent quality of life

• Ran a half marathon

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What's the worst symptom?

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Believe it or not, it’s the constant lethargy.

Nausea has never been much of a problem

and it has responded to the medicines. Even

being sick isn’t a problem. Its just feeing

exhausted all the time. The other thing is

when I get bloated it feels really

uncomfortable and I find it difficult to breathe.

That can be pretty frightening

38 year old female

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What makes me an expert on MBO?

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I do read your feedback

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“I thought it was irresponsible of Simon Noble to

praise David Currow’s research so

unquestioningly. As an audience we should be

allowed to make up their own minds.

I was also bothered by Simon’s general demeanor

throughout the whole conference.”

ASP/PCC Congress Evaluation

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• 3-15% of all cancers

• 10-28% colorectal cancers

• 5.5-42% ovarian cancers

• Spontaneous resolution 36%

• Recurrence 60%

Malignant bowel obstruction

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Non medical management: sooner rather than later.

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Medical management of MBO

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• Antiemetics

• Acid suppression

• Gut decompression

• Nasogastric

• Venting gastrostomy

• Parenteral antisecretory agents

• Anticholinergics

• Somatostatin analogues

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Levels of evidence

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Weber C, Merminod T, Herrmann FR, Zulian GB. Prophylactic anti-

coagulation in cancer palliative care: a prospective randomised study.

Support Care Cancer. 2008 Jul;16(7):847-52

• 1:1 randomization thrombopropylaxis/ placebo pall care patients

• Doppler is suspected VTE

• 10 recruited to each arm

• Thromboprophylaxis arm: 1 DVT, 1 major haemorrhage. 5 dead at 3

months.

• Control arm: no DVT, 2 non major bleeds. 9 dead at 3 months.

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Weber C, Merminod T, Herrmann FR, Zulian GB. Prophylactic anti-

coagulation in cancer palliative care: a prospective randomised study.

Support Care Cancer. 2008 Jul;16(7):847-52

• 1:1 randomization thrombopropylaxis/ placebo pall care patients

• Doppler is suspected VTE

• 10 recruited to each arm

• Thromboprophylaxis arm: 1 DVT, 1 major haemorrhage. 5 dead at 3

months.

• Control arm: no DVT, 2 non major bleeds. 9 dead at 3 months.

• So what can we conclude from this study?17

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BUGGERALL

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What did the authors conclude?

BUGGERALL

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What did the authors conclude?

BUGGERALL

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Weber C, Merminod T, Herrmann FR, Zulian GB. Prophylactic anti-

coagulation in cancer palliative care: a prospective randomised study.

Support Care Cancer. 2008 Jul;16(7):847-52

• 1:1 randomization thrombopropylaxis/ placebo pall care patients

• Doppler is suspected VTE

• 10 recruited to each arm

• Thromboprophylaxis arm: 1 DVT, 1 major haemorrhage. 5 dead at 3

months.

• Control arm: no DVT, 2 non major bleeds. 9 dead at 3 months.

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Somatostatin Analogues

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@drcrouchback

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Klein et al 2012 Systematic review

1. 21 papers reviewed

2. 14 observational studies

3. 3 controlled studies (inadequately powered)

• Octreotide vs HBB n=15

• Octreotide vs HBB n=17

• Octreotide vs HBB n=68

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Octreotide vs HBB

• Octreotide provided greater improvement in vomiting episodes

and nausea at day 3

• Similar relief at day 6 (in responders)

Vomits/day Octreotide Hyoscine BB

Baseline 3.8 4.9

Day 3 0.8 1.9

Mystakidou K et al. (2002)

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9/26/2019

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420 unique studies identified

Obita et al, JPSM 2015

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• 7 RCTs (6 octreotide, 1 lanreotide)

• 3 vs placebo, 4 vs hyoscine butylbromide

• 4 inadequately powered/ high risk of bias

• 2 adequately powered/ low risk of bias

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420 unique studies identified

Obita et al, JPSM 2015

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• 7 RCTs (6 octreotide, 1 lanreotide)

• 3 vs placebo, 4 vs hyoscine butylbromide

• 4 inadequately powered/ high risk of bias

• FAVOURS SOMATOSTATIN ANALOGUE OVER

HYOSCINE BUTYLBROMIDE

• 2 adequately powered/ low risk of bias

• DOES NOT SUPPORT SOMATOSTATIN ANALOGUE

OVER PLACEBO

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Adequately powered RCTs

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Intervention Comparat

or

Days Outcome Risk of Bias

Currow et al.

2015

Octreotide

600mcg/hr

N.saline Days 3 Vomit free days

No. vomits

Low in 6

domains

Mariani et al

2012

Lanreotide

10mg

Placebo Day 7 Proportion with 1 or

fewer voms/ day

Low in 4

domains

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To consider

1. Outcome measure

2. Control arm

3. Dose of octreotide

4. Oral intake not standardized

5. Increased use of HBB in octreotide arm

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Confirmation Bias

• Tendency to search for , interpret, favour and recall information in a

way that confirms ones pre-existing beliefs or hypotheses

• Type of cognitive bias

• Systematic error of deductive reasoning

• Occurs when people gather or remember information selectively or

interpret in a biased way

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What is the way forward?

1. The studies had different primary and secondary end points

• Number of days free of vomiting

• Number of vomits per day

• Proportion of patients who had one or fewer episodes of

vomiting per day

• Secretion volumes via NG or via vomitus

• Intensity of nausea

• Pain

• Drowsiness

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Need a standard set or core outcome measures

• Systematic review or outcome measures

• Expert consensus meeting

• Patient interviews

• Delphi

• Standardized way of reporting MBO that is meaningful to patients

but can be applied to evaluate clinical change in an way that is of

meaning in research and clinical practice.

• RAMBO

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Very helpful clever dick but what should we do

until the definitive RCT has been done?

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1. Consistent message and goals

Notes: further details here (or delete)

Source: details here (or delete)

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2. What bothers them most?

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2. What bothers them most?

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2. What bothers them most?

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2. What bothers them most?

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3. What are they prepared to accept?

Notes: further details here (or delete)

Source: details here (or delete)

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4. What realistic goal are they trying to achieve?

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• Decrease volume of vomit

• Reduce nausea

• Reduce number of vomits per day

• Remove bloated feeling

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5. Suggested approach

In mechanical bowel obstruction:

• ranitidine 150mg + dexamethasone 8mg

+ IV fluids + comfort PO fluids

– if colic add HBB 60–80mg/24h & titrate p.r.n.

– if constant background pain add opioids

• review after 3 days; if vomiting persists:

– add HBB 60–80mg/24h, or

– ↑ HBB to 120mg/24h49

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Suggested approach

• review after 3 days; if vomiting persists:

– if not already, ↑HBB to 120mg/24h, or

– consider octreotide 500–750microgram/24h

- add to HBB when colic

- substitute for HBB when no colic

– consider NG tube;

- earlier with high level obstruction

- or complete lack of response.50

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