Symptomatic relief possible with surgery for metastatic bowel obstruction

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1. Palliative operative intervention to relieve metastatic bowel obstruction can result in symptom relief, resumption of eating and home discharge.

2. Surgery under these circumstances has a high rate of mortality, complication rates and reobstruction.

Evidence Rating Level: 2 (Good)

Study Rundown: This systematic review examined the effect of palliative surgery on metastatic bowel obstruction (MBO). Many patients had improved symptoms, were able to tolerate a diet and ended up going home following the operation. However, there was a high rate of postoperative mortality, complications and reobstuction, resulting in readmissions and reoperations. This study used Cochrane Collaboration guidelines for systematic reviews, however, most of the included studies were of low methodologic quality with only five studies scoring moderate to high on methodologic quality. The patients had an extensive variety of primary cancers resulting in peritoneal metastases and ten studies focused only on ovarian cancer patients. In addition, it is difficult to come to strong conclusions about postoperative patient satisfaction as no quality-of-life or patient distress metrics were reported. Similarly, quality markers for end-of-life care such as family meetings or DNR discussions were not recorded. Despite its limitations, surgeons should discuss these findings with their patients and ensure they understand that the opportunity for symptom relief must be weighed against the serious risks of surgery.

Click to read the study in JAMA Surgery

Relevant Reading: Management of malignant bowel obstruction

In-Depth [systematic review]: This study screened 2347 articles on palliative surgical intervention for intestinal obstruction secondary to metastatic cancer. Authors selected 17 studies to review. These were published between 1982 and 2012 and included a total of 868 patients. Most studies were retrospective single-institution case series, five were retrospective cohort studies and only one was a prospective cohort study, which was conducted at a single institution. Various means of alleviating metastasis-induced obstruction were compared to surgical intervention, including exploratory laparotomy, gastric drainage, octreotide treatment, percutaneous endocscopic gastrostomy and colonic stents. Surgical intervention was equally varied and no protocol was established, allowing the surgeon to decide the most appropriate operation.

The outcomes from palliative surgery were encouraging. Between 32% and 100% of patients had improved obstructive symptoms, 45% to 75% tolerated a postoperative diet and 34% to 87% were discharged home. Serious complications occurred often – in 7% to 44% of patients, while 30-day mortality rates ranged between 6% and 32%. Moreover, 6% to 47% patients experienced reobstruction. Worse off, only 32% to 71% of patients had no symptoms or tolerated diet after 60 days. Readmission rates were reported to be as high as 74%, but only 2% to 15% needed additional surgical intervention. Mean length of survival after the diagnosis of metastatic bowel obstruction was 26 to 273 days.

By Asya Ofshteyn and Chaz Carrier

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