R E V I E W

R E V I E W
Surgical Approaches to Malignant
Bowel Obstruction
Lucy Helyer, MD, MSc, CCFP, FRCSC, and Alexandra M. Easson, MD, MSc, FRCSC, FACS
T
he three patients in the case studies on
page 106 (Box 1) have different presentations, disease progression, and treatment
options; however, they all have bowel
obstruction due to an advanced intra-abdominal
malignancy. Although all of the patients in these
cases have colorectal cancer, similar presentations occur in any advanced cancer metastasizing
within the abdominal cavity, such as pancreatic
adenocarcinoma; small cell lung cancer; and gastric, endometrial, and ovarian cancers, as well as
mesothelioma and genitourinary cancers.1,2
Malignant bowel obstruction (MBO) can be defined as a heterogeneous clinical syndrome in which
a patient has obstructive symptoms due to the presence of intra-abdominal, malignant, neoplastic disease.3 In the literature, the term MBO has been used
interchangeably for a diverse group of patients ranging from those with a potentially curable single site
of obstruction from colon cancer4 to those patients
with diffuse carcinomatosis from advanced intra-abdominal cancer.5 This wide range of diagnoses has
made management recommendations for MBO difficult and confusing. Within the palliative care field,
however, the definition has generally been reserved
for bowel obstruction in the advanced cancer setting. A recent consensus conference6 has defined
MBO using the criteria listed in Table 1. It is hoped
that the use of such a standard definition will allow
for the development of trials and protocols that will
lead to evidence-based recommendations for the
management of MBO.7
The authors acknowledge the Clinical Epidemiology Program
and Department of Health Policy, Management, and Evaluation, University of Toronto.
Manuscript submitted December 7, 2007;
accepted January 4, 2008.
Correspondence to: Alexandra M. Easson, MD, Department
of Surgical Oncology, Princess Margaret Hospital, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada; telephone: (416) 946-2328; fax: (416) 946-4429; e-mail: Easson.
[email protected]
J Support Oncol 2008;6:105–113
VOLUME 6, NUMBER 3
© 2008 Elsevier Inc. All rights reserved.
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MARCH 2008
Abstract The management of patients with malignant bowel obstruction (MBO) can be one of the most challenging aspects of advanced cancer care, and as a result, their symptoms are often palliated poorly, especially near the end of life. The term MBO encompasses a heterogeneous
clinical syndrome, defined as obstructive symptoms due to the presence
of intra-abdominal neoplastic disease. Radiological imaging, particularly
with computed tomography, is critical in determining the cause of obstruction and possible therapeutic interventions. Options include laparotomy with or without a stoma, decompression with a stent, or aggressive medical therapy. Surgical decision-making involves the selection of
the intervention most likely to relieve symptoms and improve quality of
life for a particular patient at that particular point along his or her disease
course. Although MBO is a relatively common dilemma encountered in
clinical practice, there are no simple treatment guidelines or algorithms
to follow. Instead, each patient must be assessed individually to devise
a treatment plan that best balances the advantages and disadvantages
of the intervention, considering the patient’s prognosis, tumor biology,
and—most importantly—his or her goals of care, as determined through
an honest discourse between physician and patient. This review outlines
a surgical framework for clinicians managing patients with MBO.
The management of patients with MBO is influenced by the level of obstruction, pattern of
disease, clinical stage of cancer related to prognosis, and prior anticancer treatments, as well as the
patient’s health. Treatment of these patients can
be one of the most challenging clinical scenarios,
balancing the advantages and disadvantages of
intervention with their prognosis, tumor biology,
and quality of life.
Etiology
The etiology of MBO is varied, and all solid
tumors with abdominal or gastrointestinal metastases must be considered in the differential
diagnosis. The most common etiologies of MBO
are colorectal and ovarian cancers.8 Retrospective reviews show that 10%–28% of patients with
colorectal cancer will develop MBO in the course
of their disease, whereas 20%–50% of patients
with ovarian cancer present with symptoms of
www.SupportiveOncology.net
Dr. Helyer is Assistant
Professor of Surgery,
Dalhousie University,
and Surgical Oncologist,
Division of General
Surgery, Queen
Elizabeth II Health
Sciences Centre, Halifax,
Nova Scotia, Canada.
Dr. Easson is Assistant
Professor of Surgery,
University of Toronto,
Division of General
Surgery, Mount
Sinai Hospital,
and Department of
Surgical Oncology,
Princess Margaret
Hospital, Toronto,
Ontario, Canada.
105
Surgical Approaches to Malignant Bowel Obstruction
Box 1: Case Studies
Definition of Malignant Bowel Obstruction
CASE 1
Mr. T is an 81-year-old man with chronic obstructive
pulmonary disorder who presented with a 5-day history
of progressive abdominal cramps and distention. He had
passed no flatus for 12 hours and had constant discomfort in the left lower quadrant. Over the past 6 months,
he had noted a change in his bowel function and a 10-lb
weight loss. On examination, his abdomen was distended
and firm, and his rectal exam was normal. Abdominal/
pelvic computed tomography (CT) scan with rectal contrast showed an apple-core lesion in the sigmoid colon
with complete large bowel obstruction and nearly complete replacement of his liver with metastatic disease.
What is the best way to relieve his obstruction without compromising his quality of life or life span?
CASE 2
Mr. M is a 38-year-old married lawyer with two young
children who presented with progressive fatigue, weight
loss, decreased appetite, and abdominal cramps. Physical
exam revealed a Virchow’s node (a palpable supraclavicular node indicating metastatic disease from an abdominal
primary) and a firm abdomen with no masses and no ascites. Abdominal CT scan showed diffuse peritoneal cancer
deposits with no solid organ involvement. A right-sided
mass in the retroperitoneum was causing partial obstruction of the terminal ileum and ureter. The diagnosis was
thought to be metastatic colorectal cancer arising in the
appendix. The patient wants everything done to prolong his life and enable him to enjoy time with his family.
What is the best way to manage this patient’s symptoms?
CASE 3
Mrs. P was a 54-year-old woman who presented to the
emergency room with progressive nausea and vomiting. Her
colon had been removed 3 years prior for ulcerative colitis
and colon cancer, and peritoneal deposits were seen at this
time. She had been on chemotherapy and was now admitted with complete small bowel obstruction from extensive
pelvic peritoneal disease. She suffers from constant nausea
and vomiting despite all medications, and the only thing
that alleviates her symptoms is a nasogastric tube. She wants
to see her daughter graduate from medical school in two
months and would like to do this without a tube in her nose.
How can this be facilitated?
bowel obstruction.9 Intestinal involvement of metastatic cancer commonly presents as diffuse peritoneal carcinomatosis or
more rarely (~10% of cases) as an isolated gastrointestinal
metastasis.10 Breast cancer or melanoma are the most common non-gastrointestinal causes of MBO and can occur many
years from primary presentation.10
Tumor causes obstruction in many fashions, and more than
one may be instrumental at any time. Intraluminal obstruction
106
Table 1
www.SupportiveOncology.net
1. Clinical evidence of bowel obstruction (via history/physical/
radiographic examination)
2. Bowel obstruction beyond the ligament of Treitz
3. Intra-abdominal primary cancer with incurable disease
4. Non-intra-abdominal primary cancer with clear intraperitoneal
disease
Reproduced with permission from Elsevier6
results from tumor growth within the bowel, as in polypoid
melanoma lesions or annular adenocarcinoma in the sigmoid
colon. Intramural obstruction is caused from tumor spread
within the wall of the bowel and produces poor motility due to
intestinal linitis plastica.
Extramural obstruction, probably the most common cause
of obstruction in patients with advanced cancer, reflects tumor growth within the abdominal cavity that causes external
compression of the bowel. For instance, carcinomatosis with
ovarian, peritoneal, or omental metastases can cause multilevel obstruction involving both the small and large bowels;
this is an example of a mechanical obstruction. Motility disorders due to metastatic tumor are often difficult to diagnose
but result from the infiltration of cancer into the mesentery,
bowel wall muscle, or celiac or enteric plexus, producing a
nonfunctional or a motile segment of bowel; this is considered
functional obstruction. These mechanisms of obstruction are
complicated by the concomitant use of medications, such as
narcotics and chemotherapeutic agents that affect bowel motility, absorption, or the bowel itself, resulting in perforation
or dysfunction.9
Bowel obstruction in patients with cancer may not always
be due to malignancy. In historic case series, up to 50% of
bowel obstructions in cancer patients were due to a benign
etiology, such as an adhesive band or hernia.11,12 Therefore, it
is imperative that all cancer patients with symptoms of bowel
obstruction undergo investigations to determine the cause of
obstruction and rule out any emergent, and potentially correctable, problem.
Diagnosis and Initial Management
The presentation of MBO is rarely sudden or acute; instead, MBOs are characterized by their pervasive and escalating nature. Patients complain of abdominal cramps, episodic nausea and vomiting, and abdominal distention. This
constellation of symptoms usually presents periodically and
then resolves with the passage of gas or loose stool. Episodes
of obstruction become more frequent and last longer until
near-to-complete obstruction results. This gradual presentation means that the management of these cases is rarely an
emergency, and time can and should be taken to create a
treatment plan. Initial management includes clinical assessment to rule out acute causes of obstruction and to ensure
THE JOURNAL OF SUPPORTIVE ONCOLOGY
Helyer and Easson
that the patient does not have a surgical emergency. The
patient is resuscitated with fluid to replace any losses from
vomiting, and a nasogastric tube may be used to decompress
the proximal bowel and alleviate the patient’s acute symptoms. A diagnosis of MBO requires both clinical acumen and
radiologic investigations; abdominal X-rays are generally diagnostic. Although the location of the obstruction often can
be determined by the nature and presentation of symptoms
(Table 2), radiologic characterization, primarily with computed tomography (CT) scan, is recommended for management decisions.6
Radiologic examinations play a decisive role in diagnosing the cause of the obstruction. Advances in cross-sectional
imaging have led to continued improvements in the ability
to differentiate between malignant and benign disease. Suri
et al13 showed that CT had a sensitivity of 93%, a specificity of 100%, and an accuracy of 94% in determining causes
of bowel obstruction, rates that were much better than those
with ultrasonography and plain X-ray. In another series,14 the
correct level of obstruction and its etiology were determined
in 93% and 87% of cases using CT; however, in all radiologic
modalities, the experience of the radiologists was an important
determinant.14 Carcinomatosis may be missed on CT; studies
in both colorectal and ovarian cancer patients show the diagnostic accuracy of CT is poor (< 20%) for deposits less than
0.5 cm or for deposits located in the pelvis, on the mesentery,
or on the small bowel.15–17 In one study, the use of CT scans
altered management plans in 21% of cases.18
Magnetic resonance imaging (MRI) has also been used.
Low et al19 showed that MRI had a diagnostic sensitivity of
93%, a specificity of 63%, and an accuracy of 81%. Another
institution using an MRI protocol to eliminate motion artifact reported a sensitivity, specificity, and accuracy of 95%,
100%, and 96%, respectively, which were higher than the reported CT evaluation of the same cases at the same institution (71%, 71%, 71%).20 Diagnostic indicators for both CT
and MRI have been identified and, if present, increase the
likelihood of predicting malignant obstruction. These indicators include a mass at the site of obstruction, the presence
of lymphadenopathy, an abrupt transition zone, and irregular bowel wall thickening.19–21 Clinically, radiological imaging
with CT (and/or potentially MRI) has become indispensable
in deciding whether a surgical or medical management plan
would be most effective to relieve obstructive symptoms in
patients with MBO.
Problems With the Literature
Although MBOs are commonly encountered in clinical
medicine, there are few prospective studies measuring the
success of palliation with different management plans, such as
surgery, chemotherapy, or supportive care, or measuring the
effects of treatment on the patient’s quality of life. The lack
of a consistent definition has already been mentioned, and as
a result, most series include patients at different points along
their disease trajectory, making the interpretation of the litera-
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Table 2
Differentiating the Location of Bowel
Obstruction Based on History and Symptoms
SYMPTOM
GASTRIC OR PROXIMAL
SMALL BOWEL
DISTAL SMALL BOWEL
OR LARGE BOWEL
Vomiting
Bilious, watery
Large amounts
No to little odor
Pain
Early symptom
Peri-umbilical
Short intermittent
cramps
Abdominal
distention
Anorexia
May be absent
Particulate
Small volumes
Foul odor
May be absent
Late symptom
Localized, deep visceral
pain, long intervals
between cramps
Often described as crampy
Present
Always
May not be present
ture difficult.22 Another problem is the absence of an accepted
definition of what constitutes a successful palliative intervention. Survival of 30 or 60 days after an intervention has been
used, though the use of survival time as an outcome is problematic in the advanced cancer population, where palliative
interventions are defined as those performed to relieve symptoms and improve quality of life, not necessarily to lengthen
life span.23,24 Success has also been measured as the rate of
hospital discharge or the ability to tolerate oral supplementation for a given length of time (30 or 60 days).22,25,26 Both
of these definitions are subjective in nature and reveal little
about the success or failure of an intervention. More importantly, none of the above definitions accounts for the patients’
quality of life and, ultimately, the quality of their death. It is
hoped that future trials that use patient-perceived outcomes
as the primary outcome measure will help better define what
constitutes a successful intervention.
Nevertheless, patients continue to present with MBO, and
interventions can improve symptoms. Careful assessment of
the patient will determine which patients can be helped and,
by selecting among the available options, recommendations
for the best approach for an individual patient.
When Not to Operate:
MBO From Generalized Carcinomatosis
MBO from generalized carcinomatosis is a distinct entity,
one that responds poorly or not at all to surgical intervention.
Such obstructions are usually partial and intermittent and do
not involve strangulated or twisted bowel at risk of perforation.
They are caused by blockage at multiple levels of the small and/
or large bowel, possibly complicated by motility disorders secondary to bowel wall infiltration by the tumor and/or compromise of the parasympathetic and sympathetic nerves responsible for peristalsis. Symptoms may resolve temporarily with
nasogastric decompression, but they will recur. When such
patients are taken to the operating room, the results are generally poor, with a high 30-day mortality (21%–40%) and a high
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Surgical Approaches to Malignant Bowel Obstruction
complication rate (20%–40%); unfortunately, most will re-obstruct within a short period of time.27,28 Despite advances in
anesthesia and surgical practices over the past 50 years, reports
of morbidity and mortality from patients’ treated surgically for
MBO remain high, even with good patient selection.29,30
The healthcare community is increasingly recognizing that
patients experiencing MBO through generalized carcinomatosis are best managed with aggressive medical care, including
the use of octreotide, corticosteroids, and antinausea medications. In the majority of cases, this care path allows for the
management of symptoms without a nasogastric tube. The
pharmacologic, noninvasive management of the main symptoms of bowel obstructions is well established, addressing nausea and vomiting, intestinal colic, and deep visceral pain thorough the use of appropriate drug combinations described by
Baines and Ripamonti.28,31 Two drug strategies, corticosteroids
and octreotide, have revolutionized the palliation of inoperable patients and are considered to be the cornerstones of the
medical management of MBO.
Corticosteroids have been advocated to reduce peritumoral inflammatory edema and improve intestinal transit,
inducing both temporary symptom relief and reduction in
obstruction. They also act by diminishing the secretion of
water and salts into the lumen of the bowel. Corticosteroids
have a low incidence of side effects and do not affect overall
survival. However, a 2000 Cochrane review found a trend
for improved resolution of MBO only with the use of 6–16
mg of dexamethasone.22 Mercadante et al32 also found less
than convincing data to support the use of corticosteroids in
patients with MBO and suggested that ongoing research is
needed in this area.
In three randomized trials, octreotide has been compared with hyoscine butylbromide, a classic drug used as
an antisecretory agent.33–35 All studies found octreotide decreased gastric secretions, allowed earlier removal of nasogastric tubes, and was more effective in controlling vomiting. However, these studies included only a small number
of patients. The introduction of a sustained-release formula
of octreotide may be more practical in this population of
patients, as it minimizes the need for daily injections and
at-home nursing care.
Surgical Decision-Making in MBO
Despite the morbidity and complication rates in this patient population, surgical management has a clear and definite role in the care of patients with MBO. The selection of
patients who will benefit from these procedures is an ongoing
challenge and can be done only by individualizing management. Absolute and relative contraindications to proceeding
with palliative surgery have been identified from retrospective case series, examining characteristics associated with
high rates of mortality and morbidity, and translated into
prognostic criteria.28 These criteria may be subdivided into
patient factors, disease factors, and operative factors. Editorials, expert opinions, and case series report that the pres-
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ence of one or more of these risk factors should temper the
use of surgery in patients with MBO.36–43
PATIENT FACTORS
Patient characteristics associated with poor outcomes from
an operative approach to palliation of MBO include advanced
age (both physiological and chronological), nutritional status,
performance status, concurrent illness and comorbidities, previous and future anticancer treatment, psychological health, and
social support.4,22,31,36–43 Advanced age is reported to be associated with a worse prognosis. Tekkis et al,4 dividing patients into
10-year age categories, found an increasing odds ratio of 1.85
of dying in the postoperative period per 10-year age increase
from 65 to over 85 years. Age with and without the presence
of cachexia was also identified in several studies examining the
prognosis of patients with MBO from ovarian cancer.36,43 Poor
performance status, as measured by the American Society of
Anesthesia classification (ASA) or other validated instruments,
is also associated with a poor prognosis post surgical intervention.4,37 Patients with an ASA of 2 versus 1 were found to have
an increased odds ratio of 3.3 of dying postoperatively.4
Nutritional status as measured by weight loss, cachexia,
hypoalbuminemia, or low lymphocyte count must be assessed.
Those patients with poor nutritional status are three times
more likely to die after palliative surgery for MBO than those
with a good nutritional status.31,38 In addition, patients with
persistent ascites are also at risk of a poor outcome; however,
there is little consensus in the amount of fluid required to be
considered ascites. Jong et al39 predicted patients with > 3 L
of ascites were at an increased risk, whereas Higashi et al40
more recently found that ascites of ≥ 0.1 L was predictive of a
poor outcome.
Exposure to previous adjuvant therapy is also related to the
prognosis post surgical palliation. Patients who have received
abdominal or pelvic radiation generally have higher complication rates post surgery and consequently higher rates of mortality.8 Treatment with chemotherapy does not impact surgical
complications unless the patient is malnourished or frail from
this treatment. However, the overall exposure to chemotherapy limits its successful use after surgical intervention for MBO
and ultimately impacts patient survival.29,40,42 Recent abdominal surgery is associated with poor prognosis post laparotomy
for MBO; this outcome relates to a failed initial attempt at
palliation, due to extensive or rapidly progressive disease, and
the inherent increase in surgical complications that outweigh
the potential benefit of a second laparotomy.44,45
DISEASE FACTORS
Disease factors such as etiology, time from primary presentation, tumor grade, and tumor extent affect both the ability
to surgically palliate MBO and the patient’s prognosis after
the operation. For instance, MBOs of colorectal origin have a
better prognosis and are generally more amenable to surgical
palliation than MBOs of another origin.5 The intrinsic pathologic characteristics of the tumor are important in assessing
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Helyer and Easson
the patient’s likely prognosis with a surgical palliative procedure. Patients with well differentiated tumors have a better
prognosis in comparison with those with poorly differentiated
tumors.4,41 The time from primary presentation to the development of MBO should also be considered; the longer this
time, the better the prognosis, due to the biology and inherent
growth characteristics of the tumor.41
In addition, the presence and degree of distant disease
should be considered. Patients with bilobar liver metastases
have a much worse prognosis than a similar patient without
metastatic disease; similar observations have been made in
patients with lymph node metastases.46–49 The degree of tumor
burden and its location must also be considered in planning
surgical palliation. Patients with diffuse carcinomatosis have a
poor prognosis, as they present with multiple sites of obstruction in association with ascites, leaving them with limited
palliative surgical options for relief.5 In general, patients with
multilevel obstruction due to diffuse carcinomatosis are not
candidates for surgery, and they should be offered aggressive
medical management.
OPERATIVE FACTORS
There are a number of options available to the surgeon when
considering operative interventions, and the one most likely to
relieve symptoms for the greatest length of time with reasonable operative morbidity should be the one chosen. Complete
surgical resection of a tumor is most desirable, though it is only
worthwhile—with few exceptions—if the entire tumor in that
area can be resected with negative margins. One exception is
in the setting of ovarian cancer, where chemotherapy can be
given to good effect in patients who have undergone ‘debulking’
operations. Otherwise, debulking of a tumor is not generally of
benefit, as the tumor will only grow back.
If the tumor cannot be resected, but there is healthy, nonobstructed bowel before and after the site of obstruction, a
side-to-side bypass can be performed. This will restore bowel
continuity and allow the patient to eat and maintain nutritional status for as long as possible. In the case of distal obstruction, a stoma can be created out of the most distal unaffected bowel segment. To maintain one’s own nutrition, it is
necessary to have a minimum of 100 cm of proximal bowel
before a stoma, so the length of proximal bowel should be
measured to assess this option’s feasibility. Before creating a
proximal jejunal stoma, consider that proximal stomas have a
propensity toward high output and may cause significant fluid
balance problems for the patient. Finally, in the absence of
any other options, an open gastrostomy tube may be placed to
avoid the need for a nasogastric tube.
With careful, preoperative planning, it is possible to determine before the operation which option is most likely to
succeed; however, the final decision has to be made in the
operating room after consideration of all the factors that
have previously been discussed. In determining a patient’s
prognosis with a surgical intervention, one final consideration is the timing of the intervention and the type of
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operation proposed. Although MBO is not an emergent
situation, the maxim of “not letting the sun go down on a
bowel obstruction” is still used and followed, even though
patients operated on emergently have a higher rate of mortality and morbidity.4 One can hypothesize that this result is
due to poor surgical planning, preparation of the patient, or
poor perioperative patient management; still, it is obvious
that this situation should and can be avoided. Patients who
have had recent unsuccessful laparotomy have a particularly
poor prognosis, and surgery is unlikely to be beneficial for
them.44,45 The operative strategy used to resect, bypass, or divert with an ostomy is associated with patient survival but is
confounded by the burden and location of disease. The ability to resect the obstruction is associated with a prolonged
patient survival and low incidence of mortality and morbidity, but this is likely due to resectable patients having minimal intra-abdominal disease that causes only one localized
area of obstruction (ie, colonic obstruction). Performing only
a bypass or a diverting stoma is related to poor prognosis and
higher rates of mortality and morbidity; these patients likely
have carcinomatosis or extensive disease involving both the
large and small bowels with multiple sites of obstruction and
may be better palliated with a nonsurgical option.5
Many authors have attempted to quantify the risk of surgery for a patient with MBO; however, it is difficult to judge
the risk of each prognostic factor in an individual patient.9
Gloperud43 predicted a 44% mortality in women with two adverse features and a diagnosis of ovarian cancer. Jong et al39
predicted successful surgical palliation in the absence of palpable abdominal or pelvic masses, with a volume of ascites less
than 3 L, unifocal obstruction, and preoperative weight loss
< 9 kg. Consequently, we propose that each patient should
be assessed considering the previously discussed factors, balancing the risks and benefits of proceeding with surgery, the
nonsurgical options, and the patient’s goals and expectations
(Figure 1).
Other Treatment Approaches
Due to the unlikeliness of good palliation and the high
mortality rate of surgery for MBOs, other treatment avenues
have been explored, including stent placement, tube decompression, and medications. The placement of stents and tubes
will be addressed briefly in the following paragraphs; the use
of medications for MBO relief in this patient population is beyond the scope of this discussion.
STENTING
Colonic stenting is an alternative that provides relief from
a single site of obstruction by avoiding both surgery and the
creation of a stoma while maintaining the patency of the gastrointestinal tract. A self-expanding metallic stent is inserted via
fluoroscopy with or without the help of endoscopy while a patient is under sedation.50 Several groups have attempted to determine the success rate of stenting and the impact on patient
care.50–52 Unfortunately, it is difficult to delineate the patient
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Surgical Approaches to Malignant Bowel Obstruction
Patient presenting with
symptoms of bowel obstruction
and a history of cancer
•
•
•
•
•
•
•
•
Clinical assessment
Patient acutely ill: surgical emergency. Most
patients with MBO ≠ surgical emergency
History of symptoms
Patient factors
Age: biologic/physiologic
Performance status
Stage of cancer: previous treatments,
any anticancer treatment options*
Malnutrition/cachexia
Concurrent illnesses
Ascites
•
•
•
•
•
•
•
•
Figure 1
•
•
Radiologic assessment: CT and/or MRI
Diagnosis and cause of obstruction
Site: single vs multiple
–Large vs small bowel
–Partial (most MBO) vs complete
Surgical decision making
Identify the symptom
Identify a surgical cause for the
symptom: mechanical vs functional
obstruction
Assess the realistic ability of an
intervention to alleviate the
symptom
Formulate recommendations:
NO obligation to recommend futile
therapy
•
•
•
Technical factors
Degree of invasiveness
–Interventional radiology
–Endoscopy
–Open laparotomy/laparoscopy
Anesthetic requirements
Risk of postprocedure
complications
Decision-making with patient and family
What do they understand about the disease?
What do they expect from the surgery?
Explain clearly the expected potential benefits of
the intervention: is this something that would be
worth it to them given the risks?
Does this procedure fit with the goals of care?
Algorithm for Assessing and Managing a Patient with Malignant Bowel Obstruction
Abbreviations: CT = computed tomography; MRI = magnetic resonance imaging; MBO = malignant bowel obstruction
*A discussion with the patient’s oncologist is often helpful to determine where the patient is on his or her disease trajectory.
population included in each study, as most generally combine
patients with a single, left colon obstructive lesion with those
with carcinomatosis due to widespread intra-abdominal malignancy. Overall, however, these systematic reviews50–52 comparing patients who were stented versus those undergoing surgery
conclude that stenting is highly successful for the majority of
patients and is associated with low morbidity and early functional recovery. Poor bowel function after stenting, as defined
as diarrhea, urgency, and incontinence, has been reported by
other case series examining both palliative and curative patients
and has required definitive surgery for resolution.53
Consideration of stent placement for palliation is appropriate for patients with a single colonic obstruction in the left colon.51,52,54 Placement in the transverse colon or hepatic/splenic
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flexures is difficult due to redundancy of the colon and is associated with a higher failure rate, whereas rectal obstructions
are unsuitable for stenting due to the high rate of stent migration; these obstructions are best palliated with surgery.50 The
overall survival of patients is not adversely affected by the use
of colonic stents and may be prolonged due to the increased
options of palliative treatment that can be expedited because
of the lack of surgical recovery time.55
Self-expanding metal stents have also been used with varying degrees of success for gastroduodenal, duodenal, and small
bowel obstructions from malignant disease.56–58 Due to the
short life expectancy of these patients and the significant, lifethreatening complications that can arise from stent placement,
authors advise that this procedure be performed in special-
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Helyer and Easson
Table 3
Considerations When Deciding Whether to Operate
Conduct a thorough preoperative evaluation to avoid intraoperative
surprises or emergencies.
Anticipate and prevent the obstruction from becoming an emergency
situation.
Have a frank and open discussion about what the procedure can and
cannot fix; discuss all potential outcomes of the procedure with the
patient, including the possibility of not being able to correct the problem surgically.
Discuss the patient’s thoughts about aggressive resuscitation so that
they are known in case of a bad outcome.
Provide a commitment to ongoing care with a clear care plan whatever the outcome of the surgery.
ized centers.56 Case series report that good clinical outcomes
can be expected with the relief of obstructive symptoms and
the re-introduction of oral intake. However, re-obstruction is
common, occurring in up to 30% of patients.56
In essence, there are no good published criteria to aid in
the decision to stent or operate on patients with MBO. However, the surgeon needs to be aware of the options: laparotomy
versus endoscopic stenting, indications and contraindications,
and the likelihood of success. The choice of treatment should
be made after consideration of patient factors, tumor factors,
and a history of any surgery and/or treatment. Table 3 provides
some suggestions to help facilitate this discussion between surgeon and patient.
PERCUTANEOUS DECOMPRESSION
If both surgery and endoscopic management are unacceptable choices, either because the success rate is too low or the
patient’s life expectancy is short, a venting gastrostomy tube
may provide benefit. The placement of a gastrostomy tube for
the symptomatic relief of patients with nausea and vomiting
not controlled by antiemetics has evolved slowly over the past
20 years. Clinical data are sparse and institution-dependent;
however, a tube can provide significant relief from intractable
nausea and vomiting in a patient with MBO, allowing permanent discharge from the hospital and death at home.59 Symptomatic relief from a nasogastric tube is a good prognostic factor
but not necessarily a requirement. Gastrostomy tubes should
be placed in the most dependent position of the stomach for
the best results. Ascites is a relative contraindication, but no
adverse events should be expected if the ascites is drained before placement of the gastrostomy tube. Still, placement of a
percutaneous tube is an invasive procedure, one that is associated with discomfort, complications, and failure. It should be
offered only to patients with symptoms poorly controlled with
medications and to those who are not imminently dying.59
Decision-Making in Palliative Care
Palliative care, and in turn, palliative surgery, can be defined as an approach that improves the quality of life of pa-
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MARCH 2008
tients and their families when they are facing a life-threatening
illness.60 Patients with incurable cancer are extremely vulnerable, and as such, the lines between informing, persuading, and
manipulating are fine; therefore, obtaining informed consent
for a choice such as palliative surgery can be problematic.61
Involved, well-meaning families or clinicians can sometimes
cloud the consent process, thereby superseding the patient’s
wishes with their own. There are strong moral implications for
palliative surgery and the treatment of incurable patients.62
In the face of an incurable, progressive illness, the balance
between honesty and maintaining hope and optimism can be
difficult to achieve, but it is a balance needed to avoid the pursuit of futile treatments.62 A treatment is considered futile if a
cure is physiologically impossible, if it is non-beneficial, or if it is
unlikely to produce the desired benefit. Moreover, there is little
guidance about what should be considered a futile treatment, as
the definition may vary from patient to patient and/or clinician
to clinician based on previous personal experiences and expectations. Most clinicians agree, however, that palliative surgery
in patients with cancer should not be offered to meet emotional, existential, and/or psychologic needs.61 The need to consider
palliative care is sometimes regarded by clinicians and patients
as a reflection of their personal failure and, in essence, signifies
a loss of optimism about the disease and the future.62 As a result,
the physician may feel challenged to offer treatment even if it is
futile, just as the patient may feel challenged to accept it rather
than be considered a failure. This perception by clinicians and
patients may be one of the reasons for the low referral rate to
palliative care services and hospices.
To better maintain the balance of honesty, hope, and
avoidance of a futile procedure, the patient, family, and surgeon should first address the goals of treatment. These goals
are usually directed toward the relief of suffering and the improvement of the quality of life, and they may vary between
similar patients based on perceptions and life experiences.
Next, all treatment options, including surgery, interventional
radiology, and medications, should be discussed, as well as the
indications and the related complication rates. The physician
must disclose the expected degree of success of symptom palliation for each intervention. Often, the decision to proceed
with surgery is not difficult, as it allows all parties involved to
believe that something is being done; instead, for someone in
distress, the more difficult decision is choosing against operating and doing “nothing.” In the latter case, it is important
for clinicians to maintain their commitment to providing care
and to supporting both the patient and the family throughout
the course of the disease.
Conclusion
These three cases (Box 2) show that more than one strategy
(surgery, stenting, tube placement, and/or medications) may
be used to relieve the symptoms of bowel obstruction. In fact,
depending on the progression of disease, each may be used in
succession to palliate symptoms and maintain a good quality
of life for the patient. Providing medical care to patients with
www.SupportiveOncology.net
111
Surgical Approaches to Malignant Bowel Obstruction
Box 2: Case Study Resolutions
CASE 1
After a long discussion with Mr. T and his daughter about
the choices of surgical resection, colonic stenting, or doing
nothing, Mr. T decided he would like to proceed with colonic
stenting, with a full recognition of the risk of perforation and
migration. The lesion was stented with minimal difficulty under
conscious sedation, and Mr. T was discharged home with follow-up appointments with the general surgeon and a palliative
care specialist. He died of his disease 3 months later with no
further bowel problems.
CASE 2
Mr. M. was seen by a medical oncologist, and the patient was
deemed suitable for chemotherapy if the obstruction could be
relieved. The palliative care specialist started Mr. M on octreotide
and proposed the use of corticosteroids if surgery was not indicated. A preoperative work-up suggested that, although there
were no co-morbidities and minimal ascites, the patient was malnourished, with an albumin level of 20. The radiologist and senior
surgical staff reviewed the CT scan and judged that the distal
jejunum and transverse left colon were less burdened with disease. The physician discussed the treatment options, likelihood
of their success, and possible complications at a meeting with
the patient and his family. Due to his age and young family, the
patient expressed his desire for ”any time possible“ and was mo-
MBO requires a multidisciplinary team approach, with consensus between the team members on the most appropriate strategy (surgery, stenting, or medications) and an honest, truthful
discourse between them, the patient, and the patient’s family as
to expectations and results. Patients presenting with MBO are
unique; no two have the exact same disease, extent of disease,
or goals of therapy, and consequently, the care we provide must
be tailored to their needs. The decision to proceed with surgery
tivated to proceed with surgery, with an understanding that the
procedure was not a curative option and that there were risks.
In the operating room, the surgeon found extensive disease but
no evidence of distant metastases. The mass in the right lower
quadrant was fixed to the retroperitoneum and not resectable,
and a jejunal-transverse bypass was performed. The patient recovered well and was seen post operatively for chemotherapy.
CASE 3
After extensive discussion with the medical oncologist, palliative care specialist, and the family, the group concluded that
the patient’s goal of attending her daughter’s graduation was
paramount and achievable. Despite the extent of her disease,
the patient’s performance status was such that she was able to
spend the majority of her day up in a chair and walking around.
Nausea and vomiting were her primary symptoms, and she was
started on total parenteral nutrition to prevent malnutrition.
Several attempts at percutaneous placement of a gastrostomy
tube were unsuccessful because of massively dilated, proximal small bowel loops between the stomach and abdominal
wall. She had an open gastrostomy tube placed with no complications, leading to relief of her symptoms. She attended her
daughter’s graduation with her tube hidden by a blanket and
while on minimal medications. The entire family was grateful
for this time together, and she died several months later.
requires the surgeon to consider these three questions: 1) Is the
operation technically and biologically feasible? 2) Will the procedure benefit the patient? 3) Do the patient and family understand the goals, objectives, and likely outcomes? Although the
management of a patient with MBO can be a challenging and
a surgically unsatisfying endeavor, a thoughtful and respectful
approach to the patient and this condition can produce very
rewarding patient-physician interactions.
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