Received: 1 March 2019 | Accepted: 3 March 2019 DOI: 10.1002/jso.25451 REVIEW ARTICLE Malignant bowel obstruction Robert S. Krouse MD, MS1,2,3 1 Department of Surgery, University of Pennsylvania, Philadelphia, Pennylvania 2 Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania 3 Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania Correspondence Robert S. Krouse, MD, Surgical Services (112), Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA 19104. Email: robert.krouse@va.gov Abstract Malignant bowel obstruction (MBO) is a common problem for patients with advanced malignancy, especially colorectal and ovarian cancers. Symptoms include pain, bloating, nausea and vomiting, and inability to eat. Treatment options consist of a wide range of surgical and nonsurgical interventions (medications, endoscopic, or interventional radiology approaches). Outcomes are variable no matter the strategy, and the optimal approach is often not clear. Greater research is needed to assist decision‐making for clinicians treating patients with MBO. KEYWORDS bowel, malignant, nonsurgery, obstruction, surgery 1 | INTRODUCTION are important, they should also be individualized for each patient. While it may be intuitive that relieving nausea and vomiting or the Malignant bowel obstruction (MBO) is the most common indication ability to eat are paramount, there are many social and other factors for palliative surgical consultation.1 It occurs most frequently with that influence patient priorities. In fact, being out of the acute‐care ovarian and colorectal cancers, but can be seen with other abdominal setting is often the most important goal for patients facing the end of and occasionally with nonabdominal malignancies. MBO may be life.4-10 directly related to the tumor, its treatment (eg, radiation enteritis), or benign etiologies (eg, adhesions or internal hernia). In a recent review of 334 patients with bowel obstruction and advanced malignancy, obstructions were tumor‐related in 68%, adhesion‐related in 20%, and of unclear etiology in 12%.2 2 | CLINICAL OPTIONS 2.1 | Surgical options One problem in comparing studies with MBO are variable Persistent obstructions in the face of conservative therapy (usually definitions of this condition. One accepted definition of MBO that nasogastric decompression, hydration, and bowel rest) or evidence of can provide the framework comparing patients and outcomes is: (a) complete obstructions are signs that a surgical procedure may be clinical evidence of a bowel obstruction via history, physical indicated. Many patients are deemed inoperable (6.2%‐50%).11 This examination, or radiographic examination, (b) bowel obstruction may be due to poor operative risk or relative contraindications to beyond the ligament of Treitz, (c) intra‐abdominal primary cancer surgery. Poor operative risk must be assessed based on comorbidities with incurable disease, or (d) nonintra‐abdominal primary cancer (eg, cardiac and pulmonary function), amount and location of 3 with clear intraperitoneal disease. This definition ensures that it is metastatic disease (eg, overwhelming metastasis to the liver), and established if a patient has an MBO preoperatively. Therefore, either current functional status. Potential contraindications for surgery in retrospective or prospective studies would have similar populations patients with incurable cancer and MBO include ascites, carcinoma- of patients. If determinations of MBO are changed intraoperatively, tosis and particularly the combination of ascites and carcinomatosis, comparisons to those patients who do not have an operative multiple obstructions, low albumin, multiple prior surgeries, or a procedure are flawed. In addition, this definition omits gastric outlet palpable intra‐abdominal mass.12-14 obstruction, which typically has a different treatment strategy. Although it is recognized that improvement in quality of life after The goals of treatment include relieving the symptoms of nausea, surgery is variable (42%‐85%),11,15 there is no consistent parameter vomiting, and pain, allowing oral intake, and permitting the patient to used to determine this clinical outcome. While operations may offer return to their chosen care setting. Although all goals of treatment an advantage of increased survival, surgical risks must be carefully J Surg Oncol. 2019;1-4. wileyonlinelibrary.com/journal/jso © 2019 Wiley Periodicals, Inc. | 1 2 | KROUSE considered before an operation, as morbidity (7%‐44%) and mortality Center, Houston, TX, found that percutaneous gastrostomy tubes (6%‐32%) are common, and the reobstruction rate (6%‐47%) and were utilized for palliation in 23% of small bowel obstructions in readmission (38%‐74%) is high.16 patients with advanced malignancy.24 In combination with other There is a myriad of situations one might encounter in the operating room. Typically, the approach is unknown until exploring the medical techniques, both open and percutaneous gastrostomy offers the possibility of intermittent oral liquid intake. abdomen. The optimal procedure is that which is the quickest, safest, Complications related to decompressive PEGs are rare, particu- and most efficacious in alleviating the obstruction. If due to adhesions, larly when utilized for relatively short periods of time in the setting of adhesiolysis alone might be the optimal surgical procedure. Bowel advanced malignancy.21 Venting gastrostomy tubes may also be 17,18 although bypass may be a placed percutaneously through interventional radiologic procedures. better option when resection is not possible due to tumor burden or Percutaneous gastrostomy tube placement is possible in patients deemed unsafe due to operative risks. In the setting of massive with ascites, although with a major complication rate of 10%, and carcinomatosis, the placement of a gastrostomy tube for intermittent requires ascites management with paracentesis or intraperitoneal venting might be optimal. Finally, an intestinal stoma may be necessary catheter placement.25 resection may lead to the best outcome, after resection or to adequately bypass the blockage. Laparoscopic procedures may be attempted, although this approach is often difficult due to adhesions, carcinomatosis, or 2.3 | Medical options bowel dilatation. Cytoreductive procedures (resection of intraper- When patients are admitted to the hospital, conservative mea- itoneal tumor) frequently carry high morbidity and usually are only sures (nasogastric tube, decompression, intravenous hydration, nil considered with very low‐grade tumors, such as pseudomyxoma per os (nothing by mouth)) are typically initiated. Radiologic peritonei. testing, typically including a computed tomography scan, will play a Based on large, retrospective reviews it is clear that patients large role in determining if an operation should be considered or treated with surgery have the longest survival, but this should not be only medical therapies will be implemented. While oral water‐ interpreted as evidence documenting the superiority of surgery over soluble contrast may have benefit in the benign setting, there is no medical or procedural management.2 This finding is likely a reflection evidence that it is of benefit with an MBO.26 Total parenteral of the practice of operating on patients with better performance nutrition is controversial and there is no evidence for improved status with less advanced disease. survival or quality of life.27 Palliative pharmacologic therapies have the goals of reducing intestinal inflammation and edema, and 2.2 | Endoscopic approaches for MBO controlling pain, nausea, vomiting, and dehydration. Pharmacologic options include: (1) anti‐secretory agents (eg, somatostatin analog, Endoscopic procedures are typically suited for patients who are poor steroids, scopolamine); (2) pain medications (eg, morphine); and (3) operative candidates or who decline an open operative intervention. antiemetic therapy (eg, haloperidol, prochlorperazine). The major approaches include stenting and percutaneous endoscopic gastrostomy (PEG) tube placement. Opioids act both directly to relieve pain related to intestinal obstruction, as well as to reduce painful bowel contractions against Endoscopic stent placement may obviate the need for an the obstruction. Antiemetics can be given through a variety of intestinal stoma for patients with a malignant large bowel obstruc- nonoral routes to control vomiting.28 Complete relief of emesis is tion. While less durable for the relief of obstruction than surgical achieved in a minority of patients through antiemetics alone. approaches, stenting is often more consistent with the patient’s goals Hormonal manipulation of gut activity has substantially added to of care near the end of life. Stenting may also include procedures to the armamentarium of MBO management. initially canalize the lumen (eg, laser or balloon dilatation). Octreotide, a synthetic analog of the gut hormone somatostatin, Endoluminal wall stents have a high success rate for the relief of can decrease gastrointestinal secretions and reduces bowel motility, symptoms (64%‐100%) in complete and incomplete colorectal often markedly reducing or resolving MBO symptoms.29 Duration of 19 and in over 70% of upper intestinal malignant treatment may be short‐lived (median, 9.4‐17.5 days),29 although obstructions including a gastric outlet, duodenal, and jejunal symptoms are frequently relieved for the life of the patients. In a obstructions, 20 While risks include perforation (0%‐15%), stent recent randomized controlled trial comparing octreotide with other migration (0%‐40%), or reocclusion (0%‐33%), stents can frequently standardized medical therapies, octreotide did not show a clear lead to adequate palliation for long periods of time.19 Stent occlusion benefit in the setting of MBO.30 A limitation of this study may be the by tumor in‐growth is occasionally amenable to another endoscopic primary outcome of the number of days free of vomiting as reported intervention. daily by patients over 72 hours, which may be unduly restrictive and obstructions. PEG tubes are generally well tolerated “venting” procedures that subjective. Also, there may be some patients in this trial who would can alleviate symptoms of intractable vomiting and nausea for benefit from an early operation. The authors do acknowledge that malignant small bowel obstructions and allow for discharge to home, further study is warranted. Anticholinergic medications, such as 21,22 They may also be associated with scopolamine, can decrease peristalsis and secretions and lead to fewer hospital readmissions.23 A study from MD Anderson Cancer improved control of vomiting and intestinal colic for malignant typically with hospice care. | KROUSE gastrointestinal obstruction. Corticosteroids are commonly used as adjunctive agents or alone in MBO management, with the goals of 2. decreasing tumor‐associated bowel edema and of providing antiemetic benefits. Although meta‐analysis has suggested no statistical benefit of corticosteroid use, a subset of patients may benefit from them and medication‐related morbidity is low, 31 3. particularly in patients in the terminal stages of their disease. While direct 4. comparisons of these agents have not yielded clear recommendations,32,33 a combination of these medications or “cocktail” may offer synergistic benefits over single agents.34,35 2.4 | Surgery vs medical treatments 5. 6. It is difficult to compare disparate treatment modalities without a prospective trial. Patients may be sicker who receive nonsurgical treatments,36,37 although this may be disputed.38 In retrospective 7. analyses of variable methodologies, it appears that medical management may be superior related to complications and in‐hospital death, although with no difference in overall survival. The actual quality of 8. 9. life benefits are unclear. Prospective studies in MBO, while difficult to achieve, may help guide the treatment of individual patients. 10. 3 | CONC LU SION S 11. MBO is a complex palliative care problem that surgeons often face in the acute‐care setting. For patients who have poor performance 12. status and/or very advanced disease, comfort care measures are optimal. For patients with a reasonably clear point of obstruction, 13. especially if there is evidence of ischemia, a surgical approach may be best. For most patients with MBO, outcomes and thus the ideal 14. approach is less clear. Each patient must be judged individually with discussions regarding goals of care and realistic objectives of what treatments can truly achieve. Further research is needed to help 15. surgeons with this difficult decision‐making issue. 16. A C K N O W L E D GE M E N T The author would like to thank Mary Wagner for her editing, advice, 17. and guidance of this manuscript. 18. CO NFLICT OF I NTERE ST The author declares that there are no conflict of interest. 19. OR CID 20. Robert S. Krouse http://orcid.org/0000-0002-7176-461X 21. REFERENC ES 1. Badgwell BD, Smith K, Liu P, Bruera E, Curley SA, Cormier JN. Indicators of surgery and survival in oncology inpatients 22. 3 requiring surgical evaluation for palliation. Support Care Cancer. 2009;17:727‐734. Pujara D, Chiang YJ, Cormier JN, Bruera E, Badgwell B. Selective approach for patients with advanced malignancy and gastrointestinal obstruction. 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