Management Of Malignant Bowel Obstruction Research Articles

Bowel obstruction and peritoneal carcinomatosis in the elderly. A systematic review.

There are not guidelines for surgical management of malignant bowel obstruction (MBO) caused by peritoneal carcinomatosis (PC), mainly when it involves elderly; so its treatment is still debated. To outline indications and benefits of palliative surgery for obstructive carcinomatosis and determine what prognostic factors, including age, have independent and significant association with outcome. We conducted English-language MEDLINE and EMBASE searches of articles published between 1998 and 2016, which reported outcome data after palliative surgery for MBO due to PC. We excluded all articles lacking of surgical cohort and those with main interest in conservative treatment. Of 1275 articles identified, 12 satisfied selection criteria and were included in our analysis. Overall, these studies involved 548 patients undergoing palliative surgery for MBO caused by PC. The median age was 58 (range 19-93). Relief of symptoms was achieved in 26.5-100% of cases. Postoperative morbidity ranged between 7 and 44%. Mortality was high (6-22%). The median survival was longer in surgical patients than in those receiving conservative therapy (8-34 vs 4-5weeks). Factors associated with surgery failure were poor performance status, diffuse carcinomatosis, previous radiotherapy, and obstruction of small bowel. Old age was significantly associated with a poor prognosis upon univariate analysis, while this association vanished upon multivariate analysis. Surgical palliation can provide relief of obstructive symptoms as well as improved survival in well-selected patients, even if elderly.

Management of malignant bowel obstruction

Malignant bowel obstruction (MBO) is a frequent and troubling complication in patients with cancer. The frequency of MBO has been found to be approximately 5–51% in patients with gynecological malignancies, and between 10% and 28% in primary intestinal cancers. The management of MBO challenges clinicians, patients and their families. The management of MBO includes operative surgical interventions and non-operative medical.

Using a Palliative Care Framework for Seriously Ill Surgical Patients: The Example of Malignant Bowel Obstruction.

In the recent report Dying in America: Addressing Key End of Life Issues, 1 the Institute of Medicine declared improving access to palliative care for seriously ill patients a national priority to address the crisis of low-value health care for patients near the end of life. Patients report comfort, symptom control, and dignity as central to achieving a “good death,” yet increasing numbers experience pain, unwanted health care transitions, and intensive care near the end of life. Surgeons play a critical role as providers of end-of-life care. Among Medicare decedents, almost one-third have surgery in the year before death, many in the last week of life, 2 and up to 25% of patients diagnosed as having stage IV cancer undergo a surgical procedure. Palliative care, an approach to care focused on improving quality of life for patients with lifethreatening illness and their families, is associated with improved symptom management, improved communication, and fewer care transitions for seriously ill patients. Although surgeons routinely care for seriously ill patients, the role of palliative care in surgery remains poorly defined. 3 Herein, we use malignant bowel obstruction (MBO) as an example of how surgeons can integrate principles of palliative care to support surgical care for patients with life-threatening illness. Management of MBO exemplifies the convergence of surgery and palliative care. Although survival varies based on cancer type and prognostic features, MBO is typically a late complication of advanced cancer, with life expectancy limited to weeks or months after onset. 4 Patient suffering can be immense with their remaining days fraught with high symptom burden, impaired quality of life, and hospitalization. Depending on anatomical features of the obstruction, surgical palliation via resection, bypass, or venting gastrostomy may offer select patients significant gains in quality of life. 4,5 However, substantial personal cost may accompany the pursuit of symptom relief in the form of prolonged recovery or burdensome complications, diminishing the benefits of treatment. As surgeons are increasingly called on to provide palliative interventions to seriously ill patients, their patients would benefit from strategies commonly used in palliative care to deliver goal-concordant care that is informed by patients’ values and health care priorities.

Palliative Management of Malignant Bowel Obstruction with Carcinomatosis

Mr. H was a 73 year old male with a past medical history of lumbar spinal degenerative disease, pyloric stenosis repair as a child and a Hartmann procedure for a perforated diverticulitis at age 43, with colostomy reversal shortly after.

Nonopioid pharmacological management of malignant bowel obstruction: a New Zealand-wide survey.

Malignant bowel obstruction (MBO) is a common condition among palliative patients and has limited management options. There is a paucity of widely accepted national and international evidence-based guidelines to direct the management of MBO in palliative patients. The aim of this study was to survey current practice in New Zealand of nonopioid pharmacological management of MBO and compare it with the available literature. The study utilized a survey consisting of three scenarios: probable incomplete malignant bowel obstruction (PIMBO), incomplete malignant bowel obstruction (IMBO), and complete malignant bowel obstruction (CMBO). An online survey was conducted over 2 months targeting palliative medicine practitioners working in a hospital, hospice inpatient unit, or community setting in New Zealand. Forty-eight doctors responded. Of the respondents, 56.3% used guidelines to manage MBO; however, 88.9% of the guidelines used were locally generated at the doctor's institution. Metoclopramide was the drug of choice in treating PIMBO, whereas haloperidol and hyoscine butylbromide (HB) were the preferred drugs as the severity of bowel obstruction increased. Dexamethasone was accepted as standard practice for managing all severities of MBO. A variation in the preferred starting and maximum dose of all the drugs was seen. There was a decrease in the use of laxatives and enemas as the severity of MBO increased. Variation in practice for managing MBO was evident among doctors in New Zealand. There is a need for national and international evidence-based guidelines to help define best management for the differing severities of this problematic condition.

EVALUATION OF SHORT AND LONGER-TERM SURVIVAL FOLLOWING NON-RESECTIONAL PALLIATIVE SURGERY FOR ADVANCED COLORECTAL CANCER

IntroductionPalliative surgery for advanced colorectal cancer is associated with high morbidity and mortality. Non-resectional palliative surgery can be useful in the management of malignant bowel obstruction or perforation where a...

The Role of Palliative Surgery in Gynecologic Cancer Cases

The decision to undergo major palliative surgery in end-stage gynecologic cancer is made when severe disease symptoms significantly hinder quality of life. Malignant bowel obstruction, unremitting pelvic pain, fistula formation, tumor necrosis, pelvic sepsis, and chronic hemorrhage are among the reasons patients undergo palliative surgeries. This review discusses and summarizes the literature on surgical management of malignant bowel obstruction and palliative pelvic exenteration in gynecologic oncology.

A scoring system for the prognosis and treatment of malignant bowel obstruction

Malignant bowel obstruction is a common result of end-stage abdominal cancer that is a treatment dilemma for many physicians. Little has been reported predicting outcomes or determining the role of surgical intervention. We sought to review our experience with surgical and nonsurgical management of malignant bowel obstruction to identify predictors of 30-day mortality and of who would most likely benefit from surgical intervention. A chart review of 523 patients treated between 2000 and 2007 with malignant bowel obstruction were evaluated for factors present at admission to determine return to oral intake, 30-day mortality, and overall survival. Propensity score matching was used to homogenize patients treated with and without surgery to identify those who would benefit most from operative intervention. Radiographic evidence of large bowel obstruction was predictive of return to oral intake. Hypoalbuminemia and radiographic evidence of ascites or carcinomatosis were all predictive of increased 30-day mortality and overall survival. A nomogram of 5 identified risk factors correlated with increased 30-day mortality independent of therapy. Patients with large bowel or partial small bowel obstruction benefited most from surgery. A second nomogram was created from 4 identified risk factors that revealed which patients with complete small bowel obstruction might benefit from surgery. Two nomograms were created that may guide decisions in the care of patients with malignant bowel obstruction. These nomograms are able to predict 30-day mortality and who may benefit from surgery for small bowel obstruction.

Surgical Management of Malignant Bowel Obstruction: At What Price Palliation?

Several options exist to palliate malignant obstruction (MBO), none of which have established consensus among surgeons. The purpose of this study was to establish outcomes of diverting stoma (DS), internal bypass (IB), and palliative resection (PR) for a tertiary academic referral surgical oncology service. All patients presenting to a surgical oncology service with malignant bowel obstruction over a 3-year period were identified. Records were reviewed to determine success of diversion, bypass, or resection and associated cost, length of stay (LOS), morbidity, and mortality. Forty-three patients undergoing palliative surgery were identified. The success of each approach was 80, 78, and 63 per cent for diversion, bypass, and resection, respectively. Major morbidity (63%), mortality (16%), and LOS (26 days) were greatest in those undergoing PR, but so was survival (8.4 months). DS and IB had comparable morbidity (40 and 33%), mortality (10 and 0%), and LOS (25 and 21 days), but survival was shorter for DS (5.3 vs 6.5 months). Cost of PR was significantly greater ($79,000) than both DS ($36,000) and IB ($51,000). Escalation in complexity of palliative measures for MBO results in improved survival but at significant cost both economically and physiologically. Quality of life should be discussed with patients when deciding how best to palliate their symptoms.

Malignant bowel obstruction in advanced cancer patients: epidemiology, management, and factors influencing spontaneous resolution

Malignant bowel obstruction (MBO) is a frequent complication in advanced cancer patients, especially in those with abdominal tumors. Clinical management of MBO requires a specific and individualized approach that is based on disease prognosis and the objectives of care. The global prevalence of MBO is estimated to be 3% to 15% of cancer patients. Surgery should always be considered for patients in the initial stages of the disease with a preserved general status and a single level of occlusion. Less invasive approaches such as duodenal or colonic stenting should be considered when surgery is contraindicated in obstructions at the single level. The priority of care for inoperable and consolidated MBO is to control symptoms and promote the maximum level of comfort possible. The spontaneous resolution of an inoperable obstructive process is observed in more than one third of patients. The mean survival is of no longer than 4–5 weeks in patients with consolidated MBO. Polymodal medical treatment based on a combination of glucocorticoids, strong opioids, antiemetics, and antisecretory drugs achieves very high symptomatic control. This review focuses on the epidemiological aspects, diagnosis, surgical criteria, medical management, and factors influencing the spontaneous resolution of MBO in advanced cancer patients.

A Prospective Study on the Efficacy of Octreotide in the Management of Malignant Bowel Obstruction in Gynecologic Cancer

Malignant bowel obstruction (MBO), of which symptoms lead to a poor quality of life, is a common and distressing clinical complication in advanced gynecologic cancer. The aim of this study was to prospectively assess the clinical efficacy of octreotide to control vomiting in patients with advanced gynecologic cancer with inoperable gastrointestinal obstruction. Patients with advanced gynecologic cancer, who presented at least one episode of vomiting per day due to MBO, were enrolled in this prospective study from 2006 to 2009. Octreotide was administered when necessary at doses starting with 300 μg up to 600 μg a day by continuous infusion for 2 weeks. Primary end point was vomiting control, which was evaluated by common terminology criteria for adverse events version 3 (CTCAE v3.0). Adverse events were also evaluated by CTCAE v3.0. Twenty-two cases were enrolled in this study. Octreotide controlled vomiting in 15 cases (68.2%) to grade 0 and 3 cases (13.6%) to grade 1 on CTCAE v3.0. Overall response rate to octreotide treatment was 81.8% in our patients' cohort. Among 14 cases without nasogastric tube, the overall response rate was 93.1% (13/14). Among 8 cases with nasogastric tube, 4 cases were free of tube with decrease of drainage, and overall response rate was 62.5% (5/8). No major adverse events related to octreotide were reported. We conclude that 300-μg/d dose of octreotide was effective and safe for Japanese patients with MBO by advanced gynecologic cancer. Octreotide could contribute to better quality of life by avoiding placement of nasogastric tube.

Regional audit on the symptomatic management of nausea & vomiting in the medical management of malignant bowel obstruction

BackgroundMalignant bowel obstruction is a recognised complication of advanced malignancy. Surgery is not always suitable therefore antiemetics are the mainstay of symptomatic management. There is little evidence for any specific...

An audit of the multidisciplinary management of malignant bowel obstruction on an oncology ward in an acute tertiary hospital

BackgroundMalignant bowel obstruction is common in advanced cancer. It is frequently associated with a poor prognosis. Management is complex and requires multidisciplinary input. Though management decisions need to be individualised,...

Pharmacological treatment of bowel obstruction in cancer patients

Introduction: Malignant bowel obstruction (MBO) is a common complication of advanced cancer, occurring most frequently in gynaecological and colorectal cancer. Its management remains complex and variable. This is in part due to the lack of evidence-based guidelines for the clinicians involved. Although surgery should be considered the primary treatment, this may not be feasible in patients with a poor performance status or advanced disease. Advances have been made in the medical management of MBO which can lead to a considerable improvement in symptom management and overall quality of life.Areas covered: This review emphasizes the importance of a prompt diagnosis of MBO with early introduction of pharmacological agents to optimize symptom control. The authors summarize the treatment options available for bowel obstruction in those patients for whom surgical intervention is not a feasible option. The authors also explore the complexities involved in the introduction of parenteral hydration and total parenteral nutrition in this group of patients.Expert opinion: It is not always easy to distinguish reversible from irreversible bowel obstruction. Early and aggressive management with the introduction of pharmacological agents including corticosteroids, octreotide and anti-cholinergic agents have the potential to maintain bowel patency, and allow for more rapid recovery of bowel transit. A combination of analgesics, anti-emetics and anti-cholinergics with or without anti-secretory agents can successfully improve symptom control in patients with irreversible bowel obstruction.

Management of Patients with Malignant Bowel Obstruction and Stage IV Colorectal Cancer

Malignant bowel obstruction (MBO), a serious problem in stage IV colorectal cancer (CRC) patients, remains poorly understood. Optimal management requires realistic assessment of treatment goals. This study's purpose is to characterize outcomes following palliative intervention for MBO in the setting of metastatic CRC. Retrospective review of a prospective palliative database identified 141 patients undergoing surgical (OR; n = 96) or endoscopic (GI; n = 45) procedures for symptoms of MBO. Median patient age was 58 years, median follow-up 7 months. Most (63%) had multiple sites of metastases. Computed tomography (CT) scan findings of carcinomatosis (p = 0.002), ascites (p = 0.05), and multifocal obstruction with carcinomatosis and ascites (p = 0.03) significantly predicted the need for percutaneous or open gastrostomy tube, or stoma. Procedure-associated morbidity for 81 patients with small bowel obstruction (SBO) was 37%; 7% developed an enterocutaneous fistula/anastomotic leak. Thirty-day mortality was 6%. Most (84%) patients were palliated successfully; some received additional chemotherapy (38%) or surgery (12%). Procedure-associated morbidity for 60 patients with large bowel obstruction (LBO) was 25%; 11 patients (18%) required other procedures for stent failure, with one death at 30 days. Symptom resolution was >97%. Patients with LBO had improved symptom resolution, shorter length of stay (LOS), and longer median survival than patients with SBO. Patients with MBO and stage IV CRC were successfully palliated with GI or OR procedures. Patients with CT-identified ascites, carcinomatosis, or multifocal obstruction were least likely to benefit from OR procedures. CT plays an important role in preoperative planning. Sound clinical judgment and improved understanding are required for optimal management of MBO.

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

Context The management of malignant bowel obstruction (MBO) is often challenging and frequently involves multiple treatment modalities, including chemotherapy, surgery, stenting, and symptomatic medical management. Objectives To describe the natural history of patients diagnosed with MBO who were admitted to a tertiary level hospital and followed by a multidisciplinary team that included medical oncologists, surgical oncologists, and palliative care specialists. Methods Thirty-five patients admitted under medical or surgical oncology with a diagnosis of MBO were followed over a two-year period or until the time of death. Primary malignancies included colon, rectum, pancreas, biliary, breast, bladder, carcinoid, renal cell, gastric, lung, and melanoma. Clinical outcomes of interest included survival, percentage of patients receiving surgery and/or chemotherapy, total parenteral nutrition (TPN), insertion of venting gastrostomy tube, disposition, and rates of readmission to hospital. Results Median survival was 80 days and three patients were alive at the time of study closure. At our center, 34% of patients underwent surgical intervention, 37% received at least one dose of post-MBO chemotherapy, and 43% received TPN. There was a cohort of patients (17%) who were alive at one year. Conclusion Interventions such as chemotherapy and TPN may be appropriate in a carefully selected subgroup of patients. A collaborative approach is required for the optimal clinical management and palliation of MBO.

Medical Management of Malignant Bowel Obstruction: Case Discussions and Review of Literature (713)

1.Discuss three causes of malignant bowel obstruction.2.Recognize the role of medical management of malignant bowel obstruction.3.Review two cases of malignant bowel obstruction that were successfully managed averting the need for surgery. I. Background. Malignant bowel obstruction is one of the most serious complications of colorectal and ovarian cancers. It is often caused by the presence of peritoneal carcinomatosis, intraluminal obstruction, extramural obstruction, secondary to tumor infiltration of the mesenteric plexus or secondary to adverse effects of medications including opioids, anticholinergics, and chemotherapy. Its onset is insidious, extending over many weeks or months with the symptoms of nausea, vomiting, and constipation gradually worsening. II. Case Description. Patient 1 is a 53-year-old female with a history of advanced ovarian cancer who was admitted with nausea, vomiting, and constipation for four days. She reported small bowel movements for the past month with severe abdominal pain. Physical and radiologic examinations were consistent with a cachectic, dehydrated female with high grade small bowel obstruction secondary to peritoneal carcinomatosis. She was treated with a combination of reglan, corticosteroids, octreotide, scopolamine patch, and an aggressive bowel regimen. Her pain was well controlled with an opioid PCA. There was a dramatic response in 24 hours with decreased nasogastric secretions and several bowel movements enabling discharge 3 days after admission. Patient 2 is a 61-year-old with advanced pancreatic cancer who was admitted with severe abdominal pain, nausea and vomiting. Physical and radiologic evaluations were consistent with a high jejunoileal obstruction. She was treated with reglan, corticosteroids, octreotide, and a bowel regimen. The obstruction relieved after 4 days and the patient was able to be discharged home on the fifth day after admission. III. Conclusion. Management of malignant bowel obstruction is one of the most challenging aspects of advanced cancer care. We emphasize medical management in these patients with advanced malignancies as it shortens length of hospital stay and reduces morbidity associated with surgical procedures. The main goal is palliation of symptoms in order to improve a patient's quality of life.

Maligne intestinale Obstruktion

Malignant bowel obstruction (MBO) is a frequent complication in patients with a progressive malignant disorder and represents a major interdisciplinary challenge in palliative care. Gastroenterology plays a pivotal role in the management of MBO. After appropriate diagnostic work-up, it is important to define treatment goals with the patient and his/her relatives, which should focus on symptom relief. Therapeutically, surgical, endoscopic and medical options are available. These will be introduced based on case reports. In the international literature MBO is being more and more considered as a distinct entity. The aim of the present review is to communicate MBO as such in the German medical literature.

Force Perception, Effort, Strength, and Dynamic Muscle Function in Cancer-Related Fatigue (CRF) (714)

bowel regimen. Her pain was well controlled with an opioid PCA. There was a dramatic response in 24 hours with decreased nasogastric secretions and several bowel movements enabling discharge 3 days after admission. Patient 2 is a 61-year-old with advanced pancreatic cancer who was admitted with severe abdominal pain, nausea and vomiting. Physical and radiologic evaluations were consistent with a high jejunoileal obstruction. She was treated with reglan, corticosteroids, octreotide, and a bowel regimen. The obstruction relieved after 4 days and the patient was able to be discharged home on the fifth day after admission. III. Conclusion. Management of malignant bowel obstruction is one of the most challenging aspects of advanced cancer care. We emphasize medical management in these patients with advanced malignancies as it shortens length of hospital stay and reduces morbidity associated with surgical procedures. The main goal is palliation of symptoms in order to improve a patient’s quality of life.

Surgical management for a malignant bowel obstruction with recurrent gastrointestinal carcinoma

A malignant bowel obstruction (MBO) is a common clinical complication in patients with recurrent gastrointestinal carcinoma, which has a poor prognosis and a limited life expectancy. This study considered the effectiveness of surgical management for MBO. This study reviewed the clinical course of 70 patients who underwent surgery for MBO and compared the outcomes in three groups: patients with (A) peritonitis carcinomatosis without manifest ascites, (B) peritonitis carcinomatosis with ascites, (C) local recurrence without peritonitis carcinomatosis. The 1-year survival rate and median survival time (MST) in the patients in group A were 33.3% and 228 days, which was statistically longer than those (6.7% and 46 days) in the patients in group B (P = 0.026). The rate of the patients with possible oral intake of solid meals for 6 months and median oral intake periods were 45.4% and 161 days in patients in group A and 28.0% and 93 days in patients in group C. In contrast, 66.7% in group B could not take solid meals for more than 1 month, and five patients could not take solid meals at all. Palliative operations for the patients with manifest ascites of MBO are risky and rarely effectively improve oral intake, but this is not considered to be a contraindication for surgical management. Informed consent is therefore important in the surgical management of MBO.