A Novel Approach to Palliative Bowel Decompression in Malignant Bowel Obstruction for Patients With Contraindications to Venting Gastrostomy Tube

Abstract

Introduction: Malignant bowel obstruction (MBO) is a common complication in gastrointestinal and metastatic malignancies. Beyond the immediate intervention of nasogastric tube (NGT) for decompression, the literature supports placement of endoscopic metal stents and venting gastrostomy tube (G-tube) to provide symptom relief without requiring long-term hospitalization. However, in clinical practice at MedStar Georgetown University Hospital, providers encountered difficult cases for which these standard approaches could not be offered due to contraindications to G-tube placement. Although percutaneous transhepatic biliary drainage (PTBD) procedure is not traditionally performed for bowel obstruction, it was used as alternative bowel decompression in these difficult cases. The use of PTBD in MBO has not been previously reported. We present this alternative palliative treatment approach in a case-series study to contribute to the literature as a possible intervention to consider in difficult MBO cases. Description of Cases: A total of five cases were reviewed. Patients were between 30 to 62 years old, had metastatic malignancy, were at end-stage of their disease and were diagnosed with MBO. Based on evaluation by gastroenterology, interventional radiology and general surgery teams, patients had various reasons for being deemed poor candidates for venting G-tube or endoscopic stent placements: failed decompression attempt with endoscopic stent, malignant ascites, extensive distension of bowel, difficult anatomy due to prior intra-abdominal surgeries and high peritoneal tumor burden. All patients underwent PTBD as a “last resort” attempt at relieving bowel obstruction. On pre- and post-PTBD CT scans, the radiographic evidence of bowel decompression was visualized in four cases. (Figures 1 and 2) Overall, four of five patients had symptom control and were successfully discharged home with PTBD. One case was unsuccessful due to persistent symptoms, requiring replacement of NGT. (Table 1)Figure: Pre- and post-PTBD CT images of Case #1-4 demonstrating radiographic improvement of dilated loops of bowel.Figure: Pre- and post-PTBD CT images for Case #5 showing no significant radiographic change in dilated loops of bowel. However, patient had symptomatic improvement.Table: Table. Summary of CasesDiscussion: In five palliative patients with MBO who were poor candidates for endoscopic stent or G-tube placements, with no other options beyond NGT, the placement of PTBD provided successful symptom relief, bowel decompression and discharge home in four cases. It can be a novel use of an existing procedure to provide improved quality of life in patients with end-stage MBO. More identification of cases may provide more data on complications and success rates.