Management of primary and metastatic malignant small bowel obstruction, operate or palliate. A systematic review

Abstract

Background The management of patients presenting with malignant small bowel obstruction is a challenging paradigm. The aim of this systematic review was to examine different management strategies in these complex patients. The primary outcomes evaluated were the type of intervention, 30‐day morbidity and mortality and overall survival rates. Methods A systematic literature review of EMBase, Medline, PubMed and the Cochrane Library was performed using Preferred Reporting Items for Systematic reviews and Meta‐Analyses for studies reporting on conservative and operative management of malignant small bowel obstruction. Results Fifteen studies (n = 882 patients) reporting on outcomes for malignant small bowel obstruction were analysed. Outcomes measured were primarily survival and relief of obstructive symptoms. The median age ranged from 52 to 66 years. The most common cause of malignant small bowel obstruction was gynaecological in nature (56%), followed by colorectal (19%). Four hundred and eighty‐six patients underwent primary surgical management and the remaining 396 patients were assigned to non‐surgical intervention. Median overall survival in the operative studies ranged from 2.5 to 7.4 months compared with 0.9 to 1.9 months (P < 0.05). The 30‐day mortality ranged from 13% to 28% in those who underwent surgical interventions versus 2% to 61% in the non‐surgical group (P = 0.09). No significant difference in median survival in gastrointestinal (GI) and gynaecological malignancies was observed (4.3 versus 5.0 months, P = 0.12). Morbidity ranged from 21% to 85% in the surgical group and 12% to 29% in the percutaneous groups (P < 0.05). Conclusion Surgical intervention in malignant small bowel obstruction is associated with significant morbidity, although it may improve survival in selected patients with gynaecological and colorectal malignancy. It is imperative that realistic goals and expectations are discussed with patients preoperatively.

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 …”

“…Complications related to the insertion of PEG for bowel decompression rarely occur particularly when used for relatively short periods of time in the advanced malignancy setting. Greater care is needed in patients with ascites, who have higher complication rates and require prior treatment of ascites with relief paracentesis or placement of intraperitoneal relief catheters 17,30–35 …”

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

“…Greater care is needed in patients with ascites, who have higher complication rates and require prior treatment of ascites with relief paracentesis or placement of intraperitoneal relief catheters. 17,[30][31][32][33][34][35] Recommendation: The percutaneous endoscopic procedure should only be performed by trained endoscopists or experienced interventional radiologists and should be indicated for debilitated patients, those not suitable for receiving anesthesia, and those with a life expectancy of less than 90 days. Finally, only 30% of patients who survived more than 3 months were able to benefit from TPN.…”

MASCC multidisciplinary evidence-based recommendations for the management of malignant bowel obstruction in advanced cancer

“…Following the publication of the Cochrane review, no randomized trials have been detected in our review. However, other systematic reviews have focused on studies assessing the role of surgery in specific populations with MBO, including patients with small BO or peritoneal carcinomatosis [93,106]. Similarly, it was not possible to conclude if there is a benefit on surgery in this setting, as most studies were retrospective, of low methodological quality, and high selection bias in those deemed appropriate for surgical intervention.…”