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

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

BACKGROUND

Parenteral nutrition (PN) and palliative venting gastrostomies (PVG) are two interventions used clinically to manage inoperable malignant bowel obstruction (MBO); however, little is known about their role in clinical and quality-of-life outcomes to inform clinical decision making.

AIM

To examine the impact of PN and PVG on clinical and quality-of-life outcomes in inoperable MBO.

DESIGN

A mixed-methods systematic review and narrative synthesis.

DATA SOURCES

The following databases were searched (from inception to 29 April 2021): MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, Bielefeld Academic Search Engine, Health Technology Assessment and CareSearch for qualitative or quantitative studies of MBO, and PN or PVG. Titles, abstracts and papers were independently screened and quality appraised.

RESULTS

A total of 47 studies representing 3538 participants were included. Current evidence cannot tell us whether these interventions improve MBO survival, but this was a firm belief by patients and clinicians informing their decision. Both interventions appear to allow patients valuable time at home. PVG provides relief from nausea and vomiting. Both interventions improve quality of life but not without significant burdens. Nutritional and performance status may be maintained or improved with PN.

CONCLUSION

PN and PVG seem to allow valuable time at home. We found no conclusive evidence to show either intervention prolonged survival, due to the lack of randomised controlled trials that have to date not been performed due to concerns about equipoise. Well-designed studies regarding survival for both interventions are needed.

PROSPERO REGISTRATION NUMBER

CRD42020164170.

Morbidity and Mortality of Non-pancreatectomy operations for pancreatic cancer: An ACS-NSQIP analysis

BACKGROUND

Patients with pancreas cancer may undergo palliative gastrointestinal or biliary bypass. Recent comparisons of post-operative outcomes following such procedures are lacking.

METHODS

We analyzed patients undergoing exploration, gastrojejunostomy, biliary bypass or double bypass for pancreatic cancer using data from the 2005-2019 American College of Surgeons National Surgical Quality Improvement Program. We compared 30-day mortality and complications across procedures and over time periods (2005-10, 2011-14, 2015-19) using multivariable regression models. Factors associated with postoperative mortality were identified.

RESULTS

Of 43,525 patients undergoing surgery with a postoperative diagnosis of pancreatic cancer, 5572 met inclusion criteria. Palliative operations included 1037 gastrojejunostomies, 792 biliary bypasses, 650 double bypasses, and 3093 explorations. The proportion of biliary and double bypass procedures decreased from 2005-10 to 2015-19. Gastrojejunostomy had higher 30-day mortality rate (11.5%) than other operations (p < 0.001). Adjusted 30-day mortality rates remained stable over time (7.8% vs 6.3%, p = 0.095), while rates of serious complications decreased over time (23.2% vs 17.1%, p < 0.001).

CONCLUSIONS

Palliative bypass for pancreatic cancer has not become safer over time, and 30-day mortality and complications remain high.

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

Introduction: Patients with peritoneal metastasis frequently develop malignant bowel obstruction (MBO). Medical palliative management is preferred but often fails. Conversely, the role of palliative surgery remains unclear and debated. This study aims to identify patients who could benefit from invasive surgical interventions and factors associated with successful surgical palliation.

Materials and Methods: In this retrospective study, 98 consecutive patients who underwent palliative surgery for MBO over 5 years were reviewed. We evaluate as the primary outcome surgical failure to select patients who could benefit from palliative surgery, avoiding unnecessary surgery. A prognostic score was developed based on a logistic regression model to identify patients at risk of surgical failure. The score was evaluated for overall accuracy by receiver operating characteristic curve analysis.

Results: Palliative surgery was achieved in 76 (77.5%) patients. The variables that were found to be significant factors for surgical failure are recurrent disease (P = 0.015), absence of bowel obstruction (P < 0.001), absence of bowel distension (P < 0.001), and mesenteric involvement (P = 0.001) and retraction (P < 0.001). The absence of bowel distension (P = 0.046) and bowel obstruction (P = 0.012) emerged as independent predictors of surgical failure. Carcinomatosis level assessment for peritoneum score, based on these factors, was built to evaluate the risk of surgical failure.

Conclusion: Our proposed scoring system might help select patients most likely to benefit from palliative surgery.

Malignant Bowel Obstruction Management Over Time: Are We Doing Anything New? A Current Narrative Review

INTRODUCTION

Malignant bowel obstruction from peritoneal carcinomatosis affects a significant proportion of luminal gastrointestinal and ovarian oncology patients, and portends poor long-term survival. The management approach for these patients includes a range of medical therapies and surgical options; however, how to select an optimal treatment strategy remains enigmatic. The goal of this narrative review was to summarize the latest evidence around multimodal malignant bowel obstruction treatment and to establish if and where progress has been made.

METHODS

A targeted literature search examining articles focused on the management of malignant bowel obstruction from peritoneal carcinomatosis was performed. Following data extraction, a narrative review approach was selected to describe evidence and guidelines for surgical prognostic factors, imaging, tube decompression, medical management, nutrition, and quality of life.

RESULTS

Outcomes in the literature to date are summarized for various malignant bowel obstruction treatment strategies, including surgical and non-surgical approaches, as well as a discussion of the role of total parenteral nutrition and chemotherapy in holistic malignant bowel obstruction management.

CONCLUSION

There has been little change in survival outcomes in malignant bowel obstruction in over more than a decade and there remains a paucity of high-level evidence to direct treatment decision making. Healthcare providers treating patients with malignant bowel obstruction should work to establish consensus guidelines, where feasible, to support medical providers in ensuring compassionate care during this often terminal event for this unique patient group.