title: Intestinal perforation in gynecologic oncology: do all patients benefit from surgical management?
abstract: OBJECTIVE
  To identify those patients with gynecologic cancers and intestinal perforation in whom conservative management may be appropriate.
  
  
  METHODS
  A retrospective review was performed of all gynecologic oncology patients with intestinal perforation at our institution between 1995 and 2011. The Kaplan-Meier method and Cox proportional hazards models were used to analyze factors influencing survival.
  
  
  RESULTS
  Forty-three patients met the study criteria. The mean age was 59 years (range: 38-82 years). A large number of patients had peritoneal carcinomatosis and history of bowel obstruction. Surgery was performed in 28 patients, and 15 were managed conservatively. Overall mortality at 1, 3, 6, and 12 months was 26%, 40%, 47%, and 59%, respectively. Only cancer burden at the time of perforation was independently predictive of mortality. Patients with peritoneal carcinomatosis, distant metastasis, or both were at 42 times higher risk of death than those with no evidence of disease (95% CI: 3.28-639.83), and at 7 times higher risk of death than those with microscopic/localized disease (95% CI: 1.77-29.94). When adjusted for the extent of disease spread, management approach (conservative vs. surgical) was not a significant predictor of survival (p≥0.05). The length of hospital stay (19 days vs. 7 days) and the complication rate (75% vs. 26.7%) were significantly higher in the surgical group than in the non-surgical group (p<0.05).
  
  
  CONCLUSIONS
  Patients who develop intestinal perforation in the setting of widely metastatic disease have a particularly poor prognosis. Aggressive surgical management is unlikely to benefit such patients and further impairs their quality of life.
authors.affiliation: Division of Gynecologic Oncology, Washington University School of Medicine and Siteman Cancer Center, St. Louis, MO 63110, USA. gunjalgarg@yahoo.com
authors.forename: Gunjal
authors.initials: G
authors.lastname: Garg
authors.forename: L Stewart
authors.initials: LS
authors.lastname: Massad
authors.forename: Shabnam
authors.initials: S
authors.lastname: Pourabolghasem
authors.forename: Gongfu
authors.initials: G
authors.lastname: Zhou
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Powell
authors.forename: Premal H
authors.initials: PH
authors.lastname: Thaker
authors.forename: Andrea R
authors.initials: AR
authors.lastname: Hagemann
authors.forename: Ivy
authors.initials: I
authors.lastname: Wilkinson-Ryan
authors.forename: David G
authors.initials: DG
authors.lastname: Mutch
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005833:Genital Neoplasms, Female / Q000150:complications* / Q000473:pathology / Q000601:surgery*; D006801:Humans; D007416:Intestinal Perforation / Q000209:etiology* / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D008875:Middle Aged; D009362:Neoplasm Metastasis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D015996:Survival Rate