Malignant Bowel Obstruction: Review of Symptoms & Treatment

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: [email protected]
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.
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1
2
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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.
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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.
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How to cite this article: Krouse RS. Malignant bowel
obstruction. J Surg Oncol. 2019;1‐4.
https://doi.org/10.1002/jso.25451