Current management of malignant bowel obstructions: a survey of acute care surgeons and surgical oncologists

Abstract

BackgroundMalignant small bowel obstructions (MSBOs) are one of the most challenging problems surgeons encounter, and evidence-based treatment recommendations are lacking. We hypothesized that current opinions on MSBO management differ between acute care surgeons (ACSs) and surgical oncologists (SOs).MethodsWe developed three case scenarios describing patients with previously treated cancer who developed an MSBO. Each case had five to six alternate scenarios, intended to capture the heterogeneity of MSBO presentations. Members of the Society of Surgical Oncology, the American Society of Peritoneal Surface Malignancies, and the Eastern Association for the Surgery of Trauma were asked how likely they would be to offer surgical treatment in each scenario. Responses were analyzed for factors associated with the likelihood surgeons would offer surgical management.Results316 surgeons completed the survey: 119 (37.7%) SOs and 197 (62.3%) ACSs. Overall, SOs were nearly twice as likely as ACSs to recommend surgical management. The largest differences between provider groups were seen in patients with an increased metastatic burden. In a patient with MSBO with metastatic colon cancer, both SOs (95.8%) and ACSs (94.4%) were likely or very likely to offer an operation (p=0.587); however, this fell to 91.6% and 77.7%, respectively, when this patient had multiple hepatic metastases (p=0.001). All surgeons were less likely to offer surgery to patients with multiple sites of obstruction, recurrent MSBO, and shorter disease-free intervals.DiscussionOpinions on MSBO management differ based on surgeon training and experience. Multidisciplinary management of patients with MSBO should be offered when available and increased emphasis placed on determining optimal management guidelines across specialties.Level of evidenceLevel IV Epidemiologic.

Brazilian Society of Surgical Oncology guidelines for malignant bowel obstruction management

“…Specifically in patients with MBO due to recurrent ovarian cancer, the most recent series reported the median survival times of 11.4–12.6 months for patients undergoing surgery for MBO and 3.7–3.9 months for nonsurgical patients. As reported, two essential factors, pain reduction, and reobstruction, were significantly improved by surgical palliation 28,35,61,62 …”

“…As reported, two essential factors, pain reduction, and reobstruction, were significantly improved by surgical palliation. 28,35,61,62…”

Prognostic Factors for Surgical Failure in Malignant Bowel Obstruction and Peritoneal Carcinomatosis

“…The CLAP score could reasonably allow the surgeon to understand better if it is worth taking the patient to the operating room or manage conservatively. Nevertheless, we suggest that this score must not ignore the physical examination and the caseby-case patient assessment, which remains a fundamental part of the surgeon's evaluation, frequently based on surgeon training and experience, as highlighted by a recent survey (25).…”

Inoperable malignant bowel obstruction: palliative interventions outcomes – mixed-methods systematic review

“…Those with IMBO may also be managed with parenteral nutrition (PN), gut decompression (eg, palliative venting gastrostomy (PVG), nasogastric tube drainage) or stenting 2 10. Clinical decision making is challenging, with only low-level evidence to guide clinicians in day-to-day decision making with no nationally agreed recommendations leading to wide variation between clinical centres 6 11 12. Management choices are typically based on clinicians' individual clinical experience or patients’ goals (if explored) 6…”