For most patients with recurrent ovarian cancer and intestinal obstruction, initial management should include proper radiographic documentation of the obstruction, hydration, correction of any electrolyte disturbances, parenteral alimentation, and intestinal intubation. For some patients, the obstruction may be alleviated by this conservative approach. A preoperative upper gastrointestinal radiographic series and a barium enema will define possible sites of obstruction.
If exploratory surgery is deemed appropriate, the type of operation to be performed will depend on the site and the number of obstructions. Multiple sites of obstruction are not uncommon in patients with recurrent epithelial ovarian cancer. More than one-half of the patients have small bowel obstruction, one-third have colonic obstruction, and one-sixth have both (327–331). If the obstruction is principally contained in one area of the bowel (e.g., the terminal ileum), this area can be either resected or bypassed, depending on what is easier to accomplish safely. Intestinal bypass is less morbid than resection, and in patients with progressive cancer, the survival time after these two operations is the same (332–337).
If multiple obstructions are present, resection of several segments of intestine is usually not indicated, and intestinal bypass and/or colostomy should be performed. A gastrostomy may be useful in this circumstance, and this can usually be placed percutaneously (336,339).
Surgery for bowel obstruction in patients with ovarian cancer carries an operative mortality of about 10% and a major complications rate of about 30% (325–337). The need for multiple reanastomoses and prior radiation therapy increase the morbidity, which consists primarily of sepsis and enterocutaneous fistulae. The median survival ranges from 3 to 12 months, although about 20% of such patients survive longer than 12 months (337–340).
Survival The prognosis for patients with epithelial ovarian cancer is related to several clinical variables. Survival analyses based on prognostic variables are presented (1,3,30,123–127). Including patients at all stages, patients younger than 50 years of age have a 5-year survival rate of about 40%, compared with about 15% for patients older than 50 years.
The 5-year survival rate for carefully and properly staged patients with stage I disease is as high as 94%, for stage II is 73%, for stage III or IV 28% (1). The 5-year survival rate for stage IIIA is 41%, for stage IIIB about 25%, for stage IIIC 23%, and for stage IV disease 11% (Fig. 37.16). An analysis of the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database reveals a trend toward improved survival for ovarian cancer in the United States. In this cohort, the survival for stage I was 93%, for stage II 70%, for stage III 37%, and for stage IV 25% (341).
Survival of patients with borderline tumors is excellent, with stage I lesions having a 98% 15year survival (30). When all stages of borderline tumors are included, the 5-year survival rate is about 86% to 90%.
Patients with stage III disease with microscopic residual disease at the start of treatment have a 5-year survival rate of about 40% to 75%, compared with about 30% to 40% for those with optimal disease and only 5% for those with suboptimal disease (126,127,149). Patients whose Karnofsky index (KI) is low (<70) have a significantly shorter survival than those with a KI greater than 70 (30).