Multidisciplinary ambulatory management of malignant bowel obstruction (MAMBO) program in patients with advanced gynecological cancers: A prospective study.

12076 Background: Malignant bowel obstruction (MBO) is a dreaded complication encountered in patients (pts) with advanced gynaecological cancers. Survival is short, with most pts requiring long hospital stay for managing symptoms. The aim of this study was to validate prospectively the feasibility of the MBO outpatient management by a systematic risk-stratified multidisciplinary ambulatory approach in pts with advanced gynaecological cancers. Methods: This prospective single site study enrolled pts diagnosed with or at risk of MBO due to gynaecological cancers (NCT03260647) and actively managed by the MBO interdisciplinary team including the outpatient nurse led program (PMID 31550202). Eligible pts underwent comprehensive assessments, and the team provided tailored management recommendations. Those identified as "at-risk" were systematically followed by the nursing team for 4 weeks (wks) and discharged upon complete symptom resolution. MBO patients were proactively monitored for ≥ 4 wks, transitioning to the "at-risk" category upon MBO resolution. The primary endpoint of the study was the ratio of days alive and out of the hospital to days in the hospital within the initial 60 days post-MBO diagnosis. Secondary endpoints included overall survival (OS), the rate of total parenteral nutrition (TPN) administration, and the rate of symptom resolution. Results: A total of 92 pts were enrolled, predominantly with ovarian cancer (91%), median age of 62 years (range, 31-83). At enrolment, 49% (n=45) presented with MBO, while 51% (n=47) were deemed "at risk." Proactive outpatient management by the nursing team resulted in symptom resolution in 93% of "at-risk" pts, with 7% progressing to develop MBO during the first 4 wks in the program. Throughout the study, 62% (n=57) of pts experienced MBO. At the onset of MBO, 81% (n=46) were platinum-resistant with a median of 4 prior lines of therapy (range, 0-11). While 93% of pts (n=53) required in-patient management, the median time for hospitalization durations within the first 30 and 60 days after MBO diagnosis were 7 (range, 0-30) and 12.5 (range, 0-57) days respectively. Ratio of days in hospital/days out hospital within 60 days, median (range): 0.3 (0-19). During MBO, systemic therapy was administered to 77% (n=44) of pts, predominantly with weekly paclitaxel (38%, n=21). Surgical intervention was performed in 11% of pts, included primarily diverting ileostomy in 4 pts. TPN was administered to 33% (n=19) of pts. MBO resolution occurred in 42% (n=24) pts within 60 days, with recurrent episodes in 11% (n=6) pts and MBO symptoms persisted in 58% (n=33). The median OS in pts who had an episode of MBO was 5.7 months (95% CI, 3.6-8.4). Conclusions: This study confirms the feasibility of the ambulatory MBO management with pts managed mainly outside hospital during the 60 days with reduced hospitalization days. Clinical trial information: NCT03260647 .

158 Background: Malignant bowel obstruction (MBO) is a common and challenging clinical predicament in women with advanced gynecological cancers. However, there is a lack of evidence-based guidelines or innovative approaches to improve patient care and quality of life. We implemented an inter-professional MBO management program incorporating a nurse-led ambulatory symptom management algorithm and multidisciplinary care conferences (MCC) as hallmarks of this program. Methods: Princess Margaret Cancer Centre has piloted an inter-professional MBO management program that supports women with advanced gynecological cancers who are at risk of/have developed MBO. The MBO team includes oncologists (medical, surgical, gynecologic and radiation), palliative care physicians, diagnostic and interventional radiologists, home parenteral nutrition physicians, specialized oncology nurses, dietitians, pharmacists and social workers. Complex MBO cases are discussed at regular MCC to derive treatment consensus. A symptom-driven MBO management algorithm has been devised and all patients are educated with a personalized bowel symptom management and dietary plan. For outpatient care, patients with MBO are proactively monitored by our specialized oncology nurses via phone or an eHealth bowel application to facilitate communication of symptoms and early intervention. Access to community services and home palliative care services are utilized to support care at home. All patients are enrolled into a prospective database to assess care impact and quality. Results: A total of 145 patients have been followed through the MBO management program over 12 months. At time of data cutoff, 14 had MBO (3 inpatients and 11 outpatients) and 22 were deemed at risk of MBO. Majority patients are managed as an outpatient and avoided unnecessary emergency department episodes. Detailed methodology and data analyses will be presented. Conclusions: A successful novel MBO program incorporating inter-professional care model and nurse-led ambulatory symptom management algorithm optimizes patient care in this vulnerable population and foster collaboration in implementing best practice clinical processes.

e18024 Background: Malignant bowel obstruction (MBO) in gynecologic oncology patients is associated with poor prognosis, debilitating symptoms and compromises quality of life. Management of MBO poses a clinical challenge with prolonged hospitalization. Evidence based guidelines for surgical intervention, use of chemotherapy, total parenteral nutrition or best supportive care in this patient population is lacking. Surgical correction may improve survival in selected patients. Retrospective analysis to assess impact of MBO show variable range of MBO-related admissions up to 60 days, and is associated with significant morbidity. Methods: A risk stratified MAMBO program for gynecologic patients has been implemented at Princess Margaret Cancer Centre to define a systematic approach for MBO management and build multidisciplinary consensus for personalized treatment of our patients. The program is novel and includes a nurse-led ambulatory management algorithm with an eHealth application designed to monitor bowel symptoms. A symptom-driven classification system has been devised to objectively define risk using a MBO management algorithm. Complex MBO cases are discussed in designated MBO rounds for consensus treatment recommendation. All patients with MBO are enrolled into a prospective database. Patients undergoing surgical procedures for MBO are consented for opportunistic tissue collection for translational research. MBO patient education materials have been developed to improve awareness and encourage proactive bowel symptom management. Results: Seventy nine patients have been followed through this risk stratified MAMBO program for ambulatory care over 6 months. The MBO program integrates diet, laxatives/stool softeners and drug therapy. Designated MBO rounds are now established for complex case discussion. A prospective MBO database will evaluate treatment and patient-reported outcomes. Conclusions: Risk stratified model of care for multidisciplinary MBO program facilitates decision-making between disciplines and optimize patient care in a vulnerable population with support for ambulatory care.

Malignant bowel obstruction (MBO) is a major complication in women with advanced gynecologic cancers which imposes a significant burden on patients, caregivers, and healthcare systems. Symptoms of MBO are challenging to palliate and result in progressive decompensation of already vulnerable patients with limited therapeutic options and a short prognosis. However, there is a paucity of guidelines or innovative approaches to improve the care of women who develop MBO. MBO is a complex clinical situation that requires a multidisciplinary approach to ensure the appropriate treatment modality and interprofessional care to optimally manage these patients. This review summarizes the current literature on the different approaches targeting MBO management including surgical intervention, chemotherapy, total parenteral nutrition, and pharmacological treatment. In addition, the impact of MBO management on patients' quality of life (QOL) is examined. This article focuses on the challenges in developing evidence-based treatment guidelines for MBO and barriers in clinical trial design for MBO and proposes strategies to advance the MBO management. Collaboration is essential to design studies that may improve the overall care and quality of life for these patients. Prospective data are needed to inform clinical practice, establish a new benchmark for evidence-based MBO management, and better understand the biology of MBO.

6062 Background: Malignant Bowel Obstruction (MBO) is one of the most common and devastating complications in women with gynecological cancer (GC). There is currently no consensus guideline to improve patient (pt) care in this setting. MAMBO (NCT03260647) is an ongoing prospective study evaluating the clinical implementation of a novel management algorithm for multidisciplinary management of MBO in GC pts. We report preliminary patient outcomes. Methods: All GC pts at Princess Margaret Cancer Centre with a confirmed diagnosis of or are at risk of MBO are eligible for enrollment. Participants follow a low fiber diet titrated by severity of symptom and their monthly weight and albumin levels are recorded, along with standardized patient-reported outcome measures (PROMs) at different time points. For pts who develop MBO, inpatient and ambulatory management algorithms are applied using a multidisciplinary and interprofessional care model consisting of nurses, surgeons, oncologists, radiologists, nutritionists, total parenteral nutrition team, social work, and palliative care. Decisions regarding most optimal management strategies are made by this team with regular MAMBO rounds. A retrospective analysis of pts hospitalized with MBO between 2012 and 2017 was performed in order to have a historical comparison for outcome and survival analysis using Kaplan Meier methods. Results: Since August 2017, 70 pts have been enrolled in MAMBO. Most had high-grade serous ovarian carcinoma (75%), of whom 68% are platinum-resistant. So far, 36 (51%) developed MBO, 6 of whom had multiple sequential episodes. Mean number of days in hospital with MBO was 10 days (median 7, range 0-45), compared to 18 days (median 9, range 0-134) for historical control (p = 0.009). There was no significant loss in weight 6 months from MBO diagnosis but a significant reduction in albumin level by 2.75 g/L after 3 months (p = 0.005). PROMs suggest fatigue and general lack of wellbeing were the symptoms with highest distress. Most patients (78%) received chemotherapy following MBO and most received weekly paclitaxel (36%). Median time from first MBO to death was 219 days (95% CI: 101-not reached) for all-comers in MAMBO and 174 days (95% CI: 98-363) for MBO requiring hospitalization, compared to 108 days (95% CI: 79-160) for historical controls (p = 0.007 and p = 0.062, respectively). Conclusions: Patient care and outcomes from MBO seem to be improved in GC pts enrolled in MAMBO compared to historical controls. Clinical trial information: NCT03260647.

Factors impacting length of stay and survival in patients with advanced gynecologic malignancies and malignant bowel obstruction

Malignant bowel obstruction (MBO) in patients with advanced gynecologic cancer (GyCa) can negatively impact clinical outcomes and quality of life. Oncology nurses can support these patients with adequate tools/processes. Patients with GyCa with/at risk of MBO endure frequent emergency or hospital admissions, impacting patient care. Optimizing oncology nurses' role to improve care for patients with GyCa with/at risk of MBO, the gynecology oncology interprofessional team collaborated to develop a proactive outpatient nurse-led MBO model of care (MOC). The MBO MOC involves a risk-based algorithm engaging interdisciplinary care, utilizing standardized tools, risk-based assessment, management, and education for patients and nurses. The MOC has improved patient-reported confidence level of bowel self-management and decreased hospitalization. Following education, nurses demonstrated increased knowledge in MBO management. An outpatient nurse-led MBO MOC can improve patient care and may be extended to other cancer centers, fostering collaboration and best practice.

A prospective study on the efficacy of octreotide in the management of malignant bowel obstruction in gynecologic cancer.

Background: Management of life threatening complications encountered in Advanced Cancer is an important domain of Palliative Oncology. Malignant Bowel Obstruction is usually an indicator of poor prognosis in Advanced cancer. It is usually associated with malignancies in the gastrointestinal tract or those outside the gastrointestinal tract (gynaecological malignancies). MBO can also occur with primary peritoneal as well as secondary peritoneal malignancies. Diagnostic criteria for MBO include Clinical evidence of bowel obstruction, obstruction distal to the Ligament of Treitz, presence of primary intraabdominal or extra abdominal cancer with peritoneal involvement. Materials: Detailed below are two cases of Malignant Bowel obstruction managed with Conservative inpatient nonoperative management with discussion of the proposed pharmacological protocol for the same. Case Details: A 45 year old Postmenopausal female diagnosed as carcinoma ovary stage iiic with left lower limb Deep Venous Thrombosis post multiple lines of chemotherapy including Paclitaxel plus Carboplatin, Etoposide, Tamoxifen and Liposomal Doxorubin, Malignant pleural effusion post thoracentesis was seen in the wards. A 31 year old Female a known case of moderately differentiated carcinoma colon with transmural infiltration and serosal seeding along with omental deposits with hepatic metastasis was seen in the casualty with signs of Multiple episodes of bilious vomiting with colicky abdominal pain and diagnosed to have malignant bowel obstruction on clinic radiological evaluation. Both these patients were provided non operative management of malignant bowel obstruction, were kept nil per oral, nasogastric decompression was performed with ryles tube insertion, antisecretory medication Inj Octreotide 100 ug three times daily, Anti Edema measures Inj Dexamethasone 8 mg intravrenous three times daily, Anti spasmodic and anti secretory medication Inj Hyoscine Butyl bromide 10 mg three times daily, inj Metronidazole 500 mg intravenous three times daily and Pain medication Inj Tramadol hydrochloride 50 mg intravenous in 100 ml of normal saline three times daily. Both these patients developed hyperglycemia which was managed with human regular insulin prescribed as per the sliding scale. Results: Ryles tube aspirate showed a decreasing trend and both the Patients achieved clinical resolution of symptoms underwent deintubation on Day 10 and Day 13 respectively and were taking oral feeds at the time of discharge. They were prescribed pharmacologic management of adhesive bowel obstruction consisting of Tab activated Dimethicone 40 mg three times daily, Tab Lactobacillus one tablet three times daily and Polyethylene glycol one satchet upto three times daily for 15 days at the time of discharge. Results: Resolution of symptoms can be achieved by providing non operative pharmacological management outlined above which consists of adequate hydration, parenteral nutrition when indicated, antibiotics, decongestive anti edema measures, anti spasmodic and anti secretory medication. Conclusion: Management of Hyperglycemia induced by Octreotide and Dexamethasone requires Insulin therapy. Optimum Duration, dosage and route of administration of Octreotide in management of Malignant Bowel Obstruction needs to be evaluated further.

Proactive inter-professional program to manage malignant bowel obstruction (MBO) in women with advanced gynecological cancer: Improving quality of care, education and awareness of malignant bowel obstruction among patients and health care providers

Malignant Bowel Obstruction: Natural History of a Heterogeneous Patient Population Followed Prospectively Over Two Years

PurposeDietary modification is one tool in the multidisciplinary and multi-faceted management of malignant bowel obstruction (MBO). However, the evidence for this has not been systematically explored and no guidelines currently exist. The purpose of this review was to identify the type and breadth of published evidence available to support the use of dietary modification in MBO, and to identify key characteristics of dietary interventions and outcome measures used in evaluating these interventions.MethodsSystematic searches of three databases were conducted, last in September 2024. Title and abstract screening and full-text review were conducted before data were extracted using a data extraction tool.ResultsOnly seven records met the criteria for inclusion. Quality of interventions was low, with four abstracts, one retrospective review and two feasibility studies identified. Most interventions focused on gynaecological cancers, where MBO is most prevalent. Key characteristics of dietary modification included a low-fibre diet and modification of the texture of the diet. These approaches were often used in conjunction and in a stepwise manner (progressing from liquid to soft to low-fibre diet). All records reported benefit of dietary modification, but with limited justification. The number, type and quality of records retrieved might reflect that this is a novel area of research, with local practice and clinical experience being published as abstracts. We found no methodologically robust, large-scale interventions.ConclusionThis review demonstrates a lack of evidence to support the use of dietary modification in MBO. High-quality studies assessing the efficacy and impact of dietary modification are needed to support the advice commonly being provided in clinical settings. However, this research is ethically and logistically challenging to conduct. Nutritional management guidelines based on expert consensus might be a useful resource for clinicians managing MBO given the lack of research evidence currently available to inform practice.

This is an update of the original Cochrane review published in Issue 4, 2000. 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. To assess the efficacy of surgery for intestinal obstruction due to advanced gynaecological and gastrointestinal cancer. We searched the following databases for the original review in 2000 and again for this update in June 2015: CENTRAL (2015, Issue 6); MEDLINE (OVID June week 1 2015); and EMBASE (OVID week 24, 2015).We also searched relevant journals, bibliographic databases, conference proceedings, reference lists, grey literature and the world wide web for the original review in 2000; we also used personal contact. This searching of other resources yielded very few additional studies. The Cochrane Pain, Palliative and Supportive Care Review Group no longer routinely handsearch journals. For these reasons, we did not repeat the searching of other resources for the June 2015 update. As the review concentrates on the 'best evidence' available for the role of surgery in malignant bowel obstruction in known advanced gynaecological and gastrointestinal cancer we kept the inclusion criteria broad (including both prospective and retrospective studies) so as to include all studies relevant to the question. We sought published trials reporting on the effects of surgery for resolving symptoms in malignant bowel obstruction for adult patients with known advanced gynaecological and gastrointestinal cancer. We used data extraction forms to collect data from the studies included in the review. Two review authors extracted the data independently to reduce error. Owing to concerns about the risk of bias we decided not to conduct a meta-analysis of data and we have presented a narrative description of the study results. We planned to resolve disagreements by discussion with the third review author. In total we have identified 43 studies examining 4265 participants. The original review included 938 patients from 25 studies. The updated search identified an additional 18 studies with a combined total of 3327 participants between 1997 and June 2015. The results of these studies did not change the conclusions of the original review.No firm conclusions can be drawn from the many retrospective case series so the role of surgery in malignant bowel obstruction remains controversial. Clinical resolution varies from 26.7% to over 68%, though it is often unclear how this is defined. Despite being an inadequate proxy for symptom resolution or quality of life, the ability to feed orally was a popular outcome measure, with success rates ranging from 30% to 100%. Rates of re-obstruction varied, ranging from 0% to 63%, though time to re-obstruction was often not included. Postoperative morbidity and mortality also varied widely, although again the definition of both of these surgical outcomes differed between many of the papers. There were no data available for quality of life. The reporting of adverse effects was variable and this has been described where available. Where discussed, surgical procedures varied considerably and outcomes were not reported by specific intervention. Using the 'Risk of bias' assessment tool, most included studies were at high risk of bias for most domains. 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 could 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. In order to compare outcomes in malignant bowel obstruction, there needs to be a greater degree of standardisation of management.Since the last version of this review none of the new included studies have provided additional information to change the conclusions.

BackgroundSurgical management of malignant bowel obstruction carries with high morbidity and mortality. Placement of a trans-anal decompression tube (TDT) has traditionally been used for malignant bowel obstruction as a bridge to surgery. Recently, colonic metallic stent (CMS) as a bridge to surgery for malignant bowel obstruction, particularly left-sided malignant large bowel obstruction (LMLBO) caused by colorectal cancer, has been reported to be both a safe and feasible option. The aim of this retrospective study is to evaluate the clinical effects of CMS for LMLBO as a bridge to surgery compared to TDT.MethodsBetween January 2000 and December 2015, we retrospectively evaluated outcomes of 59 patients with LMLBO. We compared the outcomes of 26 patients with CMS for LMLBO between 2013 and 2015 (CMS group) with those of 33 patients managed with TDT between 2003 and 2011 (TDT group) by the historical study. LMLBO was defined as a large bowel obstruction due to a colorectal cancer that was diagnosed by computed tomography and required emergent decompression.ResultsAll patients in the CMS group were successfully decompressed (p = 0.03) and could initiate oral intake after the procedure (p < 0.01). Outcomes in the CMS group were superior to the TDT group in the following areas: duration of tube placement (p < 0.01), surgical approach (p < 0.01), operation time (p < 0.01), number of resected lymph nodes (p < 0.001), and rate of curative resection (p < 0.01). However, no significant differences were found in the overall postoperative complication rate (p = 0.151), surgical site infection rate (p = 0.685), hospital length of stay (p = 0.502), and the need for permanent ostomy (p = 0.745). The 3-year overall survival rate of patients in the CMS and TDT groups was 73.0% and 80.9%, respectively, and this was not significant (p = 0.423).ConclusionsTreatment with CMS for patients with LMLBO as a bridge to surgery is safe and demonstrated higher rates of resumption of solid food intake and temporary discharge prior to elective surgery compared to TDT. Oncological outcomes during mid-term were equivalent.

Malignant bowel obstruction from peritoneal carcinomatosis affects a significant proportion of luminal gastrointestinal and ovarian oncology patients, and portends poor long-term survival. The management approach for these patients includes a range of medical therapies and surgical options; however, how to select an optimal treatment strategy remains enigmatic. The goal of this narrative review was to summarize the latest evidence around multimodal malignant bowel obstruction treatment and to establish if and where progress has been made. A targeted literature search examining articles focused on the management of malignant bowel obstruction from peritoneal carcinomatosis was performed. Following data extraction, a narrative review approach was selected to describe evidence and guidelines for surgical prognostic factors, imaging, tube decompression, medical management, nutrition, and quality of life. Outcomes in the literature to date are summarized for various malignant bowel obstruction treatment strategies, including surgical and non-surgical approaches, as well as a discussion of the role of total parenteral nutrition and chemotherapy in holistic malignant bowel obstruction management. There has been little change in survival outcomes in malignant bowel obstruction in over more than a decade and there remains a paucity of high-level evidence to direct treatment decision making. Healthcare providers treating patients with malignant bowel obstruction should work to establish consensus guidelines, where feasible, to support medical providers in ensuring compassionate care during this often terminal event for this unique patient group.