Malignant Bowel Obstruction Research Articles

Malignant bowel obstruction: a comparison among pre-operative factors, surgical approaches, and survival. Is surgery worthwhile?

Background: Malignant bowel obstruction (MBO) is defined as the evidence of obstruction distally to the Treitz ligament in the presence of a malignant peritoneally disseminated neoplasm. Patients with this condition suffer from decreased quality of life due to impaired food intake, recurrent nausea, and abdominal pain. The objective was to investigate the outcome of patients with MBO surgically treated, considering post-treatment survival, surgical morbidity, and length of hospital stay, in order to assess the efficiency and impact of surgery at this advanced stage of disease. Methods: We reviewed retrospectively data collected from 198 patients diagnosed with MBO at Instituto do Câncer do Estado de São Paulo (ICESP), operated between 2018 and 2021. Results: Among preoperative factors, advanced stages and poor clinical status were associated with earlier death (stage IV had 4.53 higher chance of death). On the other hand, patients considered candidates for invasive life support measures had longer postoperative survival (non-candidates had a chance 1,000,000 times higher of death). Primary diagnosis also showed to be an important risk factor: ovary malignancies had higher risk of surgical complications (OR of 14.28), when compared to gastric and colon cancers. Considering intraoperative factors, patients who underwent resections had better long-term survival (9.9 months) than those who underwent bypass (1.3 months) or stomas (2 months); p=0.017. Finally, considering post-operative factors, long-term survival was associated with shorter hospital stay (p=0.001). Conclusions: Medical and surgical treatment should be employed on a case-by-case basis, after taking into consideration multiple pre-operative factors, such as KPS and primary tumor stage.

Outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal dissemination from ovarian carcinosarcoma

BackgroundOvarian carcinosarcoma (OCS) is an uncommon and aggressive malignancy, with poor response to current treatment approaches and no clear guidelines. Our aim is to evaluate the outcomes of an OCS cohort after cytoreduction with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). MethodsA descriptive cohort study was performed. Patients who underwent CRS/HIPEC for peritoneal dissemination from tubo-ovarian malignancies (1999–2021) were retrospectively reviewed. Patients with confirmed histopathologic diagnosis of FIGO stage III/IV OCS were included. Overall (OS) and progression-free survival (PFS) were determined with the Kaplan-Meier method. ResultsOf 267 patients with tubo-ovarian malignancies reviewed, 7.5% (20/267) had OCS. Of these, 16 underwent CRS/HIPEC, including 9 for a new diagnosis and 7 for disease recurrence. Median age at surgery was 66.5 (IQR: 54.5–74.5) years. Nine (56.2%) patients were FIGO stage IV. Median peritoneal cancer index was 22 (IQR: 14–28). Complete cytoreduction was achieved in 15/16 (93.7%) cases. HIPEC agents included carboplatin (n = 7), cisplatin+doxorubicin (n = 4), and melphalan (n = 5). Major complications occurred in 4/16 (25%), with no 90-day mortality. Median follow-up was 41.8 months. Median PFS was 11.7 (95%CI: 10.5–17.1) months. Malignant bowel obstruction occurred in 3/16 (18.7%). Median OS from CRS/HIPEC was 21.3 (95%CI: 16.3–31.6) months, not reached for newly diagnosed vs 19.7 months for recurrent patients (p = 0.23). ConclusionsCRS/HIPEC showed promising survival and abdominal disease control with low rates of malignant obstruction in patients with advanced stage OCS. Collaborative studies with larger cohorts and longer follow-up may further elucidate the role of CRS/HIPEC in OCS.

Home parenteral nutrition in advanced cancer: do current guidelines accurately predict survival benefit to support decision-making for patients with ovarian cancer and inoperable malignant bowel obstruction?

Home parenteral nutrition in advanced cancer: do current guidelines accurately predict survival benefit to support decision-making for patients with ovarian cancer and inoperable malignant bowel obstruction?

High-quality phase 3 studies do not support the use of somatostatin analogues to reduce vomiting in malignant bowel obstruction

High-quality phase 3 studies do not support the use of somatostatin analogues to reduce vomiting in malignant bowel obstruction

Management of left-sided malignant colorectal obstructions with curative intent: a network meta-analysis.

Several management options exist for colonic decompression in the setting of malignant large bowel obstruction, including oncologic resection, surgical diversion, and SEMS as a bridge-to-surgery. Consensus has yet to be reached on optimal treatment pathways. The aim of the present study was to perform a network meta-analysis comparing short-term postoperative morbidity and long-term oncologic outcomes between oncologic resection, surgical diversion, and self-expanding metal stents (SEMS) in left-sided malignant colorectal obstruction with curative intent. Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared two or more of the following in patients presenting with curative left-sided malignant colorectal obstruction: (1) emergent oncologic resection; (2) surgical diversion; and/or (3) SEMS. The primary outcome was overall 90-day postoperative morbidity. Pairwise meta-analyses were performed with inverse variance random effects. Random-effect Bayesian network meta-analysis was performed. From 1277 citations, 53 studies with 9493 patients undergoing urgent oncologic resection, 1273 patients undergoing surgical diversion, and 2548 patients undergoing SEMS were included. Network meta-analysis demonstrated a significant improvement in 90-day postoperative morbidity in patients undergoing SEMS compared to urgent oncologic resection (OR0.34, 95%CrI0.01-0.98). Insufficient RCT data pertaining to overall survival (OS) precluded network meta-analysis. Pairwise meta-analysis demonstrated decreased five-year OS for patients undergoing urgent oncologic resection compared to surgical diversion (OR0.44, 95%CI0.28-0.71, p < 0.01). Bridge-to-surgery interventions may offer short- and long-term benefits compared to urgent oncologic resection for malignant colorectal obstruction and should be increasingly considered in this patient population. Further prospective study comparing surgical diversion and SEMS is needed.

Abstract No. 174 Relief When it Matters Most: Decompressive Percutaneous Transesophageal Gastrostomy for Long-term Management of Malignant Bowel Obstruction

Abstract No. 174 Relief When it Matters Most: Decompressive Percutaneous Transesophageal Gastrostomy for Long-term Management of Malignant Bowel Obstruction

Long-term outcomes between self-expandable metallic stent and transanal decompression tube for malignant large bowel obstruction: A multicenter retrospective study and meta-analysis.

To compare the oncological outcomes between self-expandable metallic stent (SEMS) as a bridge to surgery and transanal decompression tube (TDT) placement for malignant large bowel obstruction (MLBO). A total of 287 MLBO patients who underwent SEMS (n=137) or TDT placement (n=150) were enrolled in this multicenter retrospective study. Overall survival (OS) and disease-free survival (DFS) between the two groups were compared. A meta-analysis was performed using random-effects models to calculate odd ratios (OR) with 95% confidence intervals (CIs). Postoperative complications of Clavien-Dindo grade ≥II and ≥III occurred frequently in the TDT group compared with the SEMS group (P=0.002 and 0.005, respectively). The 3-y OS in the overall cohort and 3-y DFS in the pathological stage II/III cohort in the SEMS and TDT groups were 68.6% and 71.4%, and 71.0% and 72.6%, respectively. The survival differences were not significantly different in the OS and DFS analyses (P=0.819 and P=0.892, respectively). A meta-analysis of nine studies (including our cohort data) demonstrated no significant difference between the SEMS and TDT groups for 3-y OS and DFS (OR=0.96, 95% CI=0.57-1.62, P=0.89 and OR=0.69, 95% CI=0.46-1.04, P=0.07, respectively). Our study demonstrated that SEMS placement had no inferiority regarding long-term outcomes, including OS and DFS, compared with TDT placement. Considering the short-term benefits of SEMS placement, this could be a preferable preoperative decompression method for MLBO.

Delaying surgery for optimization after colonic stent bridging is safe for left-sided malignant large bowel obstruction: Result from 10-year experience and risks factor analysis

AimTo evaluate the operative and oncological results after colonic stent bridging for left-sided malignant large bowel intestinal obstruction and the risk factors for survival and recurrence after definitive surgery. MethodologyConsecutive patients who underwent colonic stenting for malignant left-sided colonic obstruction were included. Patients for palliative stenting or emergency surgery, patient with low rectal tumour or peritoneal metastasis were excluded. The primary outcome was overall survival. Secondary outcomes included stent success rate, stenting related complications, rate of stoma formation and long-term oncological outcome including recurrence rate and recurrence free survival rate. ResultsFrom June 2011 to June 2021, a total of 222 patients underwent colonic stenting. 112 patients were bridged to surgery after initial stenting, but 7 patients dropped out. Overall survival was 35 months (IQR = 17.75–75.25 months) in the early operation group, 30 months (IQR = 17.5–49.5 months) in the delayed surgery group HR 0.981 (95%CI 0.70–1.395, p = 0.907). Sensitivity analysis performed by excluding stent complications and emergency surgery yielded the same conclusion. Overall stenting complications rate was 17.1%. 11 patients (10.4%) required emergency surgery. ConclusionThere was no difference between early and delayed surgery groups (>4weeks) in the overall survival and recurrence in patients who had stent-bridge to surgery for malignant left colonic obstruction. It is safe to defer definitive surgery to optimize patients and allow better recovery from initial obstruction after colonic stenting before definitive surgery without adversely affecting the oncological outcomes.

Treatment of obstructive colorectal cancer

Obstructive colorectal cancer is a common malignant bowel obstruction. Colostomy or colostomy following tumor resection may be the first choice for emergency surgery. The intestinal and systemic conditions of patients undergoing emergency surgery are often poor, and patients need to undergo multiple operations, which increase the surgical risk and economic burden and reduce the quality of life of patients. Poor intraoperative visualization may also affect the radical operation of emergency surgery. Transanal decompression tube (TDT) can rapidly decompress and drain the obstructed bowel, effectively relieve obstruction symptoms, and improve the success rate of primary radical resection. The TDT squeeze the tumor lightly, causing no spread of tumor cells, and is cheap, but the cavity of transanal decompression tube is small and easily blocked, and requires tedious flushing or regular replacement. Self-expanding metallic stents (SEMS) can relieve intestinal obstruction effectively, provide sufficient preparation time for preoperative examination and improvement of nutritional status. By improving patient's tolerance to radical surgery, SEMS might be used as an important treatment strategy choice for obstructive colorectal cancer. However, SEMS may squeeze the tumor, leading to the spread of tumor cells, increase the recurrence rate and metastasis rate, and reduce the survival rate. Moreover, intestinal wall edema still existed during the operation following SEMS, and the rate of ostomy after anastomosis was as high as 34%. We hypothesized that prolonging the interval between stent insertion and surgery to 2 months, with neoadjuvant chemotherapy administered during this interval (SEMS-neoadjuvant chemotherapy strategy), would help improve outcomes. The SEMS-neoadjuvant chemotherapy strategy is a safe, effective, and well tolerated treatment approach with a high laparoscopic resection rate, low stoma formation rate and improvement in the overall survival for patients with left-sided colon cancer obstruction. The patient physical status is improved, the primary tumor is downstaged, and intestinal wall edema is relieved during the relatively longer interval between SEMS placement and surgery. The SEMS-neoadjuvant chemotherapy strategy may be a preferred therapeutic strategy for obstructive left colon cancer.

Outcomes and survival in patients with advanced intestinal neuroendocrine tumours on home parenteral nutrition, an international multicentre retrospective cohort study

Only limited information is available on the use of home parenteral nutrition (HPN) in patients with advanced neuroendocrine tumours (NETs) causing intestinal failure (IF). This study aims to report the outcomes of the explore the use of HPN in this patient cohort, in the largest case series to date. A retrospective study in the United Kingdom and the Netherlands was performed, using the UK National British Artificial Nutrition Survey (BANS) and local databases in the Netherlands. Data regarding age, sex, NET grading, staging, treatment, HPN characteristics and survival outcomes were collected. Data were collected on 41 patients (n=18 males, 44%) with a median age of 65. Most primary tumours were in the small bowel (n=35, 85%). The NETs were Grade 1 (n=16, 39%), Grade 2 (n=7, 17%), Grade 3 (n=1, 2%). In 28 patients (n=68%) there was stage IV disease with metastases located in the peritoneum, mesentery and or liver. There were two indications for HPN; short bowel syndrome (n=27, 66%) and inoperable malignant bowel obstruction (n=14, 34%). The median period on HPN was 11 months (interquartile range 4-25 months). 11 patients were still alive and receiving HPN treatment after 2 years, and 6 patients after 3 years. Six patients (22%) with short bowel syndrome (SBS) could be weaned from HPN. There was a statistically significant improved survival for patients with short bowel syndrome (median 24 months) compared to inoperable malignant bowel obstruction (median 7 months). The catheter-related bloodstream infection rate was comparable to other HPN patient cohorts at 1.0 per 1000 catheter days. This study shows that HPN can be used safely in patients with NET and IF to increase survival beyond that reasonably expected in the context of either short bowel syndrome or inoperable malignant bowel obstruction. Patients with short bowel syndrome are most likely to benefit. Further prospective studies are necessary to validate survival benefits and to demonstrate the effect of HPN on quality of life.

Short- and long-term outcomes following bridge to surgery and emergency resection in acute malignant large bowel obstruction.

Bridge to surgery (BtS) aims to decrease perioperative morbidity and mortality in emergency resection (ER) of the colon. Previous results are inconsistent, and long-term comparisons are scarce. The aim of this study was to compare the short- and long-term outcomes of BtS and ER. This retrospective study examined data from the Swedish Colorectal Cancer Registry for patients treated for acute malignant large bowel obstruction from 2007 to 2009. Patients were grouped by treatment strategy: BtS (using a self-expanding metallic stent or diverting stoma) or ER. Medical records were scrutinized for all patients in the BtS group. The primary endpoints were 5-year overall survival (OS) and 3-year recurrence-free survival (RFS). The secondary endpoints were postoperative mortality and morbidity rates and stoma permanence. Overall, 143 patients were treated using BtS versus 1302 patients treated with ER. The 5-year OS was higher in the BtS group than in the ER group (53.8% vs. 37.4%; p < 0.05). No difference was noted in the 3-year RFS (75.7% vs. 75.0%; p=0.38). The postoperative mortality rate was lower in the BtS group than in the ER group (0.7% vs. 7.3%; p < 0.05). Complications occurred in 46.9% of patients in the BtS group (both procedures) versus 35.9% of patients in the ER group (p < 0.05); the rate of severe complications was 23.1% and 16.9%, respectively (p=0.07). This retrospective population-based registry study showed higher long-term survival and lower postoperative mortality rates among patients treated with BtS versus ER for acute malignant large bowel obstruction.

Home parenteral nutrition in patients with malignant bowel obstruction. Ethical considerations

Background: patients with cancer are one of the main group of patients on home parenteral nutrition (HPN). Patients with malignant bowel obstruction (MBO) represent a challenging group when considering HPN. At the Ethics Working Group of SENPE ethical considerations on this subject were reviewed and a guidelines proposal was made. Methods: a literature search was done and a full set of questions arose: When, if ever, is HPN indicated for patients with MBO? How should the training program be? When withdrawal of HPN should be considered? Other questions should be also taken into consideration. May any Oncologist send home a patient with HPN? The educational program could be shortened? When considering to withdraw parenteral nutrition? Results: HPN in MBO has better outcomes when patients have a good functional status (Karnofsky ≥ 50 or ECOG ≤ 2), expected survival > 2-3 months, and low inflammatory markers. Very few data have been reported on quality of life, but HPN allows a valuable time at home albeit with a considerable burden for both patients and their families. Proposal: once a patient is considered for HPN, there is a need for a deep talk on the benefits, complications and risks. In this initial talk, when HNP should be stopped needs to be included. The palliative care team with the help of the nutrition support team should follow the patient, whose clinical status must be assessed regularly. HPN should be withdrawn when no additional benefits are achieved. Conclusion: HPN may be considered an option in patients with MBO when they have a fair or good functional status and a desire to spend their last days at home.

Does a selective surgical approach to malignant bowel obstruction help in palliative care patients?

Malignant bowel obstruction (MBO) is a condition secondary to intra-abdominal metastatic spread of advanced-stage tumors. There is no consensus for the treatment approach of MBO. This study aims to present the results of medical treatment and palliative surgery in patients diagnosed with MBO. The patients who were treated for advanced-stage tumors between 2010 and 2017 and for whom consultation was requested from the surgical clinic for MBO symptoms were identified. A selective approach together with palliative care for the indication of surgery was instituted. The patients with surgical treatment and medical treatment were compared concerning survival, oral food intake and symptom relief. Seventy-six patients (30 female, 46 male) aged 60.5±12.8 years (range: 27-88) were included in this study. Forty-eight of the patients (64.9%) underwent surgical treatment, while 28 (35.1%) had medical treatment. Although the patients with surgery had longer duration of stay in the hospital (median 16 days vs. 4 days) (p<0.001) and higher complication rates (27.1% vs. 3.5%) compared to medically treated patients; the restoring oral food intake was better (97.9% vs. 78.6%) (p=0.005) and the survival was longer (105 days vs. 43 days). This study revealed that surgical treatment resulted in better outcomes for life quality parameters in highly selected patients with malignant bowel obstruction evaluated by multidisciplinary team, including palliative care.

Best Palliation for Malignant Bowel Obstruction- A Retrospective study

Objective: To determine the best palliative procedures undergone surgery and non-surgical procedures such as Chemotherapy/Stenting.

Arterial-colonic fistula secondary to colonic stent erosion into the left external iliac artery

Self-expandable metal stent (SEMS) are widely utilized as a bridge to surgical intervention and for palliative treatment of malignant bowel obstructions. The risk of complications associated with SEMS is low in well-selected patients. Stent erosion is a rare but serious adverse event that is associated with high morbidity and mortality. Here, we report the case of a 74-year-old patient with a colonic obstruction secondary to a pelvic mass that was treated with SEMS and radiotherapy, who developed a partial thickness stent erosion and recurrent hematochezia 6years after placement. Endoscopic retrieval was not technically feasible. During attempted surgical resection, massive hemorrhage occurred from a colonic-arterial fistula to the left external iliac artery resulting in death. While SEMS remain an effective, minimally invasive approach for the management of bowel obstructions, prolonged in-situ lifetime may confer an increased risk of serious adverse events including erosion and fistula formation.

Use of EUS and Stent Insertion in Symptom Management of Malignant Bowel Obstruction Following Cancer Recurrence after Whipple's Pancreaticoduodenectomy

Use of EUS and Stent Insertion in Symptom Management of Malignant Bowel Obstruction Following Cancer Recurrence after Whipple's Pancreaticoduodenectomy

Adhesive small-bowel obstruction: Conservative versus surgical management?

Bowel obstruction is a common emergency requiring acute medical care. Small-bowel obstruction (SBO) accounts for 80% of all mechanical bowel obstruction, and adhesive SBO is the most common cause of SBO. Computed tomography imaging in patients with abdominopelvic surgery history is useful to diagnose adhesive SBO (ASBO), to exclude other causes of SBO, and to identify patients who need emergency surgeries which usually are closed-loop obstruction, strangulated obstruction, or perforation. For uncomplicated ASBO, the timing when surgery has always existed controversy. Studies revealed that prolonged nonoperative management is associated with increased morbidity. On the other hand, operative management of ASBO may decrease the risk of recurrence. During the conservative management for patients who do not need emergency surgeries, gastrografin challenge may accelerate relief from obstruction and avoid unnecessary surgery, or promote surgical decision-making and avoid delayed surgery. In addition, early postoperative SBO (EPSBO) with adhesive or inflammatory causes and unresectable malignant bowel obstruction should be identified and avoided surgery, although these patients have past abdominopelvic surgery history.

Relationship Between C-reactive Protein-to-albumin Ratio Before and After Bowel Decompression and Prognosis in Acute Malignant Large Bowel Obstruction.

We investigated the relationship between prognosis and the necessity of decompression of large bowel obstruction (LBO) among patients with colorectal cancer admitted to the hospital in an emergency, as well as the correlation between prognosis and improvement in the C-reactive protein-to-albumin ratio (CAR) after decompression. Seventy-four patients admitted to the hospital between 2013 and 2021 in an emergency due to LBO were included. We examined perioperative clinicopathological factors, bowel decompression type, and prognosis. Of the 74 patients, 24 (32.4%) required bowel decompression. A higher percentage of patients who required bowel decompression had a colorectal obstruction scoring system (CROSS) score 0 (p<0.001) with higher frequency of nutritional disorders (p=0.063) than that in no bowel decompression-requiring patients. The 3-year-disease-free survival was 70.8% in the no decompression-requiring group and 26.9% in the bowel decompression group (p=0.007), while the 3-year-overall survival was 90.8% and 76.5%, respectively (p=0.001). The 3-year-disease-free survival was 49.2% in the improved CAR group and 0.0% in the non-improved CAR group (p=0.024), while the 3-year-overall survival was 91.7% and 56.3%, respectively (p=0.061). The necessity of emergency decompression was associated with a poorer prognosis, compared to the no decompression-requiring group. Similarly, a CROSS score of 0 was an independent poor prognostic factor. Among patients who required emergency bowel decompression, those who showed improvement in CAR before and after decompression treatment had a better prognosis than those who did not.

Outcomes and long-term follow-up by treatment type for patients with advanced-stage ovarian cancer managed at a tertiary cancer center: A Memorial Sloan Kettering Cancer Center Team Ovary study

ObjectiveTo assess long-term outcomes of patients with advanced-stage ovarian cancer by treatment type. MethodsPatients with newly diagnosed stage III-IV ovarian cancer who underwent primary treatment at our tertiary cancer center from 01/01/2015–12/31/2015 were included. We reviewed electronic medical records for clinicopathological, treatment, and survival characteristics. ResultsOf 153 patients, 88 (58%) had stage III and 65 (42%) stage IV disease. Median follow-up was 65.8 months (range, 3.6–75.3). Eighty-nine patients (58%) underwent primary debulking surgery (PDS), 50 (33%) received neoadjuvant chemotherapy followed by interval debulking surgery (IDS), and 14 (9%) received chemotherapy alone, without surgery (NSx). Median PFS to first recurrence was 26.2 months (range, 20.1–36.2), 13.5 months (range, 12–15.1), and 4.2 months (range, 1.1–5.8) in the PDS, IDS, and NSx groups, respectively (P < .001). At first recurrence/progression, 80 patients (72.7%) were treated with chemotherapy, 28 (25.5%) underwent secondary cytoreductive surgery (CRS) followed by chemotherapy, and 2 (1.8%) received no treatment. Seven patients (4.6%) underwent palliative surgery for malignant bowel obstruction. Overall, 62.7% received 1–3 lines of chemotherapy. The 5-year OS rates were 53.2% (95% CI: 44.7%–61%) for the entire cohort, 71.5% (95% CI: 60.2%–80%) for the PDS group, 35.2% (95% CI: 22.2–48.5%) for the IDS group, and 7.9% (95% CI: 0.5%–29.9%) for the NSx group. ConclusionThe longitudinal treatment modalities and outcomes of patients with advanced ovarian cancer described here can be useful for patient counseling, long-term planning, and future comparison studies.

Malignant bowel obstruction in peritoneal carcinosis from a serous ovarian carcinoma in a woman carrying high grade BRCA mutation: a case report

This is the second contribution of a series of updates on some of the oncological emergencies. The updates are published in the form of a case, with multiple-choice questions to assess knowledge, a brief discussion of the answer, and reference literature, to further explore the topic presented. This case involves the management of malignant bowel obstruction from an ovarian cancer.