Biomedical subjects

D J Feuer

Publications and source records attributed to D J Feuer.

5 recordsLinked to original sources

PubMed2000

Corticosteroids for the resolution of malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer.

BACKGROUND: Gastrointestinal and ovarian cancers are common cancers. The incidence of associated malignant bowel obstruction in patients with advanced cancers of these types is not known, and the best management of these patients is controversial. Inappropriate management may result in uncontrolled (faeculant) vomiting, pain and distress. Management of the symptoms can include palliative surgery, nasogastric tube suction together with intravenous fluids, or pharmacological means, such as corticosteroids. There is uncertainty regarding both the efficacy and possible harmful effects of corticosteroids, and also the most effective type, dose/dosing regime, route and period of administration. OBJECTIVES: To locate, appraise and summarise evidence from scientific studies on intestinal obstruction due to advanced gynaecological and gastrointestinal cancer, in order to assess the efficacy of corticosteroids. SEARCH STRATEGY: A comprehensive list of all studies was provided by an extensive search of the electronic databases, relevant journals, reference lists, the grey literature, contact with investigators and other search strategies outlined in the methods. SELECTION CRITERIA: As the review concentrates on the 'best evidence' available of the role of corticosteroids in malignant bowel obstruction due to advanced gynaecological and gastrointestinal cancer the inclusion criteria were kept fairly broad so as to include all studies relevant to the question DATA COLLECTION AND ANALYSIS: Data extraction forms were used to collect data from the studies included in the review. The data was checked by a secondary searcher to reduce error. A qualitative analysis was performed of the dichotomous data of resolution of obstruction and death at one month, obtained from the randomised controlled trials of corticosteroids versus placebo. Both fixed and random effect models were used. Number needed to treat (NNT) was derived from the odds ratio. Kaplan-Meier survival curves from individual patient data were also analysed. Studies of lower methodological quality were assessed in a qualitative manner. MAIN RESULTS: Three unpublished, randomised, placebo, double blind controlled trials and seven published (prospective and retrospective) trials were considered eligible. Using only the randomised trials, there is a trend, which is not statistically significant, for the resolution of bowel obstruction using corticosteroids. There is no statistically significant difference in mortality at one month, nor in the Kaplan-Meier curves, which describe the survival of patients on corticosteroids or placebo. Number needed to treat is 6 (3, infinity) ie six patients need to be treated with corticosteroids to resolve one episode of bowel obstruction. The results are robust to fixed and random effects models and to 'best' and 'worst case' scenarios on the missing data from patients. The morbidity associated with corticosteroids appears to be very low, though the quality of the data limits this conclusion. No other outcomes were available from the published data or from the authors. REVIEWER'S CONCLUSIONS: There is a trend for evidence that corticosteroids of dose range 6-16 mg dexamethasone given intravenously may bring about the resolution of bowel obstruction. Equally, the incidence of side effects in all the included studies is extremely low. Corticosteroids do not seem to affect the length of survival of these patients.

Female↗

PubMed2000

Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer.

BACKGROUND: Intestinal obstruction commonly occurs in progressive advanced gynaecological and gastrointestinal cancers. Management of these patients is difficult due to the patients deteriorating mobility and function (performance status), the lack of further chemotherapeutic options and the high mortality and morbidity associated with palliative surgery. There are marked variations in clinical practice concerning surgery in these patients between different countries, gynaecological oncology units, and general hospitals as well as referral patterns from oncologists under whom these patients are often admitted under. There is therefore a need for all the present information to be collated, analysed (with appropriate palliative care outcomes) to establish if surgery is of benefit and what further research is needed. OBJECTIVES: The objective was to locate, appraise and summarise evidence from scientific studies on intestinal obstruction due to advanced gynaecological and gastrointestinal cancer, in order to assess the efficacy of surgery. SEARCH STRATEGY: A comprehensive list of studies was provided by an extensive search of electronic databases, relevant journals, bibliographic databases, conference proceedings, reference lists, the grey literature, personal contact and the world wide web. SELECTION CRITERIA: As the review concentrates on the 'best evidence' available of the role of surgery in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer the inclusion criteria were kept broad (included both prospective and retrospective studies) so as to include all studies relevant to the question. DATA COLLECTION AND ANALYSIS: Data extraction forms were used to collect data from the studies included in the review. Two researchers extracted the data independently to reduce error. Due to the methodological quality of the studies, only a qualitative assessment was possible. MAIN RESULTS: The role of surgery in malignant bowel obstruction remains controversial, and no firm conclusions from the many retrospective case series can be made. Control of symptoms varies from 42% to over 80%, though it is often unclear how symptoms were measured and whether the tools used to collect symptom scores are validated. There is a large range in the rates of re-obstruction, from 10-50%, though time to re-obstruction was often not included. There is a wide range of postoperative morbidity and mortality, although again the definition of both these surgical outcomes varied between many of the papers. REVIEWER'S CONCLUSIONS: The role of surgery in malignant bowel obstruction needs careful evaluation, using validated outcome measures of symptom control and quality of life scores. Further information would include re-obstruction rates together with the morbidity associated with the various surgical procedures. Currently, bowel obstruction is managed empirically, and there are marked variations in clinical practice by different units. There needs to be a greater standardisation of management so that comparisons between different series can be made.

Female↗

PubMed1999

Systematic review of surgery in malignant bowel obstruction in advanced gynecological and gastrointestinal cancer. The Systematic Review Steering Committee.

OBJECTIVE: The objective was to locate, appraise, and summarize evidence from scientific studies on intestinal obstruction due to advanced gynecological and gastrointestinal cancer in order to assess the efficacy of surgery. MATERIALS AND METHODS DATA SOURCES: A comprehensive list of studies was provided by an extensive search of electronic databases, relevant journals, bibliographic databases, conference proceedings, reference lists, the gray literature, personal contact, and the worldwide web. DATA SYNTHESIS: Two researchers extracted the data independently. Due to the methodological quality of the studies, only a qualitative assessment was possible. RESULTS: The role of surgery in malignant bowel obstruction remains controversial, and no firm conclusions from the many retrospective case series can be made. Control of symptoms varies from 42% to over 80%, although it is often unclear how symptoms were measured and whether the symptom scores used are validated. There is a large range in the rates of reobstruction, from 10 to 50%, although time to reobstruction was often not included. There is a wide range of postoperative morbidity and mortality, although again the definition of both of these surgical outcomes varied among many of the papers. CONCLUSION: The role of surgery in malignant bowel obstruction needs careful evaluation, using validated outcome measures on symptom control and quality of life scores. Further information would include reobstruction rates together with the morbidity associated with the various surgical procedures. Currently, bowel obstruction is managed empirically, and there are marked variations in clinical practice by different units. There needs to be a greater standardization of management so that comparisons between different series can be made.

Female↗

PubMed1999

Systematic review and meta-analysis of corticosteroids for the resolution of malignant bowel obstruction in advanced gynaecological and gastrointestinal cancers. Systematic Review Steering Committee.

BACKGROUND: The objective was to locate, appraise and summarise evidence from scientific studies on intestinal obstruction due to advanced gynaecological and gastrointestinal cancers, in order to assess the efficacy of corticosteroids. MATERIALS AND METHODS. DATA SOURCES: A comprehensive list of studies was provided by an extensive search of electronic databases, relevant journals, bibliographic databases, conference proceedings, reference lists, the grey literature, personal contact and the world wide web. DATA SYNTHESIS: Two researchers extracted the data independently. A qualitative analysis was performed of the dichotomous data of resolution of obstruction and death at one month. Both fixed and random effect models were used. Number needed to treat (with corticosteroids to resolve one episode of bowel obstruction) was derived from the odds ratio. Kaplan-Meier survival curves from individual patient data were also analysed. Studies of lower methodological quality were assessed in a qualitative manner. RESULTS: There is a trend towards resolution of bowel obstruction using corticosteroids but this result does not achieve statistical significance. There is no statistically significant difference in mortality at one month, nor in the Kaplan Meier survival curves. Number needed to treat is 6, though with wide confidence intervals (3-infinity). The results are robust to fixed and random effects models and to 'best' and 'worst case' scenarios on the data from missing patients. The morbidity associated with corticosteroids appears to be very low. CONCLUSIONS: The role of corticosteroids needs further elucidation. More patients need to be recruited in order to obtain more precise results. Further trials should include quality of life measures as primary outcomes as well as most effective type of corticosteroid, dose or dosing regime, route of administration and morbidity.

Adrenal Cortex Hormones↗

PubMed1999

Meta-analysis.

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Humans↗