Gastroenterol Clin N Am 35 (2006) 143151

GASTROENTEROLOGY CLINICS
OF NORTH AMERICA

Surgical Palliation of Bowel Obstruction

Robert S. Krouse, MD*
University of Arizona, Tucson, AZ, USA Arizona Cancer Center, Tucson, AZ, USA

he treatment of malignant bowel obstruction (MBO) is a common dilemma encountered by all general surgeons treating cancer patients. MBO may be the presenting picture of a previously undiagnosed intraluminal tumor, or it can herald recurrent disease. Because of the advanced, incurable disease that bowel obstruction from a malignancy usually portends, treatment is considered palliative. Because bowel obstruction can occur in as many as 5% to 43% of patients with a diagnosis of advanced primary or metastatic intra-abdominal malignancy [1], it is necessary for surgeons, gastroenterologists, and oncologists to have a thorough understanding of this condition. The most common primary malignancies causing MBO are ovarian (5.5% to 51%) and colorectal (10% to 28%) cancers [2]. Nonabdominal cancers, including lung cancer, breast cancer, and melanoma, also are known to occasionally cause intestinal obstruction. The long-term known survival for these patients is poor (4 to 9 months) [3]. Although newer chemotherapeutic options may improve long-term survival [4], patients ultimately succumb to their cancers. Lower-grade tumors, such as pseudomyxoma peritonii, may have a better outlook, further warranting consideration of more aggressive treatment [5]. CAUSES OF MALIGNANT BOWEL OBSTRUCTION AND RELEVANCE TO DECISION-MAKING There are multiple causes of bowel obstruction in the cancer patient. Clearly, the cause of the obstruction, if it can be discerned, will play a role in the treatment decision-making process. Benign causes include adhesions, radiationinduced strictures, and internal hernias. The rate of benign intestinal obstruction in patients with previously diagnosed malignancy is variably reported but signicant (3% to 48%) [6], and a benign cause in the setting of an MBO must be considered even for a patient with known metastatic or unresectable

*Southern Arizona Veterans Affairs Health Care System Surgical Care Line, 2-112 Tucson, AZ 85723, USA. E-mail address: robert.krouse@med.va.gov 0889-8553/06/$ see front matter doi:10.1016/j.gtc.2006.01.003 Published by Elsevier Inc. gastro.theclinics.com

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cancer. In addition, radiation enteritis should be considered in patients with a history of abdominal exposure to radiation therapy. Bowel obstruction resulting from tumors includes mechanical and functional mechanisms. Carcinomatosis, rather than local tumor recurrence, is likely the cause of small bowel obstruction from neoplasm [37], in contrast with large bowel obstructions, which are usually at a single site [7]. The effects of mechanical obstruction by tumor may be accentuated by inammatory edema, constipation, cancer- or treatment-induced brosis, abnormalities in intestinal mobility, decreased production of intestinal enzymes and secretions, a change in fecal ora, or the adverse effects of medications [1]. SELECTION FOR SURGERY Although the overall patient status, including physical, social, psychologic, and spiritual domains, would seem mandatory considerations for palliative intervention, this big picture view is not reected in previously used selection criteria for surgery. The Krebs and Gopland prognostic index may be used to determine optimal patients for surgery [8]. This index uses age, nutritional status, tumor status, ascites, previous chemotherapy, and previous radiation therapy as the prognostic parameters. The authors dene successful palliation or benet from surgery as survival for at least 2 months. Although this index based on physical and objective parameters is used commonly, it assumes that optimal palliation is reected in survival time and not quality-of-life outcomes. Therefore, the usefulness of this index is unclear in assessing surgical palliation. Surgical intervention for MBO can have serious complications, including death. If the patient can resume an acceptable quality of life, based on the patients, caretakers, and surgeons assessments, an operation can be considered. It is also vital that the patient have a reasonable expected survival time. If a patient can be expected to live for several months after an operation, barring major complications, surgical options should be contemplated. If it is estimated that a patient has only days to a few weeks of life remaining, then a major operation seems unreasonable. Because even experienced oncologic surgeons have been shown to be frequently incorrect in their predictions of survival time following a palliative procedure [9], prognoses should be based on performance status, literature-based procedure-specic operative mortality rates, and on preoperative extent of disease. Treatment may have a secondary gain of improved survival, and this possibility should be taken into account. If the patient is deemed too sick for a surgical procedure, if an operation is unlikely to help achieve goals, or the patient refuses an operative intervention, other modalities must be recommended. It is unclear if specic contraindications to surgery can be mandated. A literature review of surgical procedures for MBO [10] found nearly all studies were retrospective, whereby no dened criteria could be discerned. Reports are variable as to the percentage of patients deemed inoperable (6.2% to 50%), with the most frequent reasons noted being extensive tumor, multiple partial

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obstructions, and inability to correct obstructions surgically [11]. Most authors agree that the criteria that suggest surgery would unlikely benet a patient include ascites, carcinomatosis, palpable intra-abdominal masses, multiple bowel obstructions, and very advanced disease with poor overall clinical status [11]. Recommendations are not uniform, as in one series of MBO caused by colorectal cancer that demonstrated that the number of sites of obstruction did not correlate with resumption of bowel function or postoperative death [12]. In elderly patients with nonovarian cancers and known large-volume ascites (at least 3 L) who undergo abdominal procedures, the perioperative mortality of 41% [13] seems prohibitive. Recurrence of MBO has been noted to be signicantly increased and symptom-free survival to be signicantly decreased for patients with as little as 100 mL of ascites [3]. Blair and colleagues found that ascites accompanying a small bowel obstruction predicted a worse outcome following surgery [14]. In one study, quality of life seemed to be signicantly better for patients with local recurrence compared with those with carcinomatosis [5]. Reoperation following a previous operation for MBO usually should be discouraged, as it has been shown that these patients have a low likelihood of successful palliation (30%) and limited survival rates [15]. Occasionally, a surgeon is faced with the dilemma of a patient with an acute or surgical abdomen and an MBO. Although a true emergency of this nature is rare [16], and decision-making is more difcult in this setting, the same operative criteria should be applied. If reasonable survival time cannot be anticipated, it is warranted not to pursue surgical options. Although it has been shown in the case of colorectal cancer obstructions that survival is quite good for emergent procedures [17,18], it is unclear from the literature how pressing were the indications to operate emergently. For large bowel obstruction causing threat of proximal perforation in a patient with limited survival expectations, intestinal stenting should be considered. If intestinal stenting is not an option, a loop colostomy, ileostomy, or blow-hole colostomy are reasonable alternatives. Surgery should be performed only after thorough discussion and clear understanding by the patient, family, and surgical team about the expected goals and outcomes of a surgical intervention. Informed consent for this necessitates explanation of possible operative complications, mortality rates from surgery and the underlying disease process, recovery time, and symptom recurrence rate. If an operation is considered, parameters should be set for future operative intervention. It is imperative that there be no miscommunication resulting in an unrealistic expectation for cure. Improvement or preservation of quality of life should be understood as the primary goal of treatment. The patient and family should be reassured they will not be abandoned regardless of the outcome of the operation. Because pain after surgery is a predictable concern, preoperative planning should include discussion of postoperative analgesia. An epidural catheter and other postoperative pain management techniques should be considered, not only for procedure-related pain, but also for ongoing cancerinduced pain. Although opioids may contribute to bowel dysfunction, they are usually necessary in the perioperative period.

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SURGICAL OPTIONS When attempting an operation for intestinal obstruction with a palliative intent, the surgeons repertoire should include a wide range of options because of the wide spectrum of operative ndings. Although the quickest and safest procedure that can alleviate the obstruction or favorably impact on symptoms should be considered, there is limited information related to the optimal procedure in the setting of a MBO. This reects the heterogeneity of the diseases that cause obstruction and the lack of patient-dened considerations in earlier published series. In localized disease, resection of the obstructed segment may afford the best outcome. Resection may entail restoration of bowel continuity. In the setting of carcinomatosis, or if a prohibitive amount of dissection is needed, alternative approaches should be used. This may include a bypass procedure, either by an enterostomy or an intestinal stoma, or simply a drainage procedure using a large gastrostomy tube. Although a gastrostomy tube alone for obstruction may not improve the ability to eat, it usually will alleviate the problems of nausea, vomiting, and pain. Patients may be able to take some form of oral diet in time. Although it has been noted that patients with resection may live somewhat longer [2] and have a slightly better quality of life [5] than those with bypass procedures, no study has addressed this issue in a randomized, prospective fashion. Based on the many different clinical presentations related to MBO, it is unlikely that such a study will take place. If a benign cause of bowel obstruction is encountered, usual surgical techniques are often applicable, but bypass or intestinal stoma may be recommended, if they will shorten the procedure and lead to less morbidity. For patients undergoing an urgent procedure for large bowel obstruction, it may be unwise to reanastamose bowel, and exteriorization of colon or ileum may be a more prudent option. In addition, a blow-hole colostomy is a potentially simpler procedure that has been used in this setting [19]. Intestinal stomas can benet the quality of life for patients with MBO greatly. Unfortunately, they frequently are avoided, as they are unsightly to patients and regarded as a failure by surgeons. Although the threat of an intestinal stoma is a major concern for patients, colostomies and ileostomies may provide a greater ease of care and minimize patient symptoms. For example, in a patient who has a complete low rectal obstruction caused by tumor along with a substantial metastatic tumor burden, placement of a loop colostomy or ileostomy is a procedure that can be performed quickly with minimal morbidity. A blowhole colostomy may be a reasonable procedure for patients who have a malignant toxic megacolon [19]. As always, ostomy placement should be considered preoperatively so that proper stoma placement can be attained. Involving a stoma nurse to help mark the possible site on the abdomen may facilitate stoma planning. In addition, involving a stoma nurse in the preoperative setting allows the patient to discuss issues and, one hopes, to allay fears [20,21]. It is imperative the patient and family members receive adequate postoperative training, because caring for a stoma is one more challenge in an already overwhelming situation. The ability for a follow-up visit with the surgical team, and

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with the ostomy nurse, is mandatory, as difculties and anxieties are sure to arise. Radiation enteritis can mimic the presentation of bowel obstruction caused by tumor even in the absence of tumor. Because of the impaired perfusion of the bowel wall resulting from radiation arteritis, trivial serosal injuries can result in major complications. The incidence of radiation enteritis is related directly to the amount of small bowel in the radiation eld and the dose of radiation received. For patients with radiation-induced obstructions, intestinal bypass rather than resection may be the preferred surgical treatment [22]. Intestinal bypass has been shown to lead to long-term alleviation of gastrointestinal obstructions and successful palliation in most patients [22]. Severe adhesions may make surgery impossible [23], and other treatments must be considered in this situation. Recently, laparoscopy has been used to bypass obstruction caused by radiation injury [24]. Laparoscopic approaches to MBO are increasingly an option, as surgeons expand the limits of these procedures. Potential advantages include reduced pain and a shorter hospital stay. Laparoscopy also may allow the diagnosis of unforeseen disease in the peritoneal cavity, which may limit surgical intervention. Laparoscopic techniques are highly dependent on surgeon experience and ability, and are usually not appropriate for patients with dense adhesions and carcinomatosis. In properly selected patients, especially those who present initially with incurable cancer and a bowel obstruction or who had only laparoscopic procedures previously, this may be a less invasive surgical option. Although indications for surgical intervention remain the same, it is likely that treatment-related morbidity and mortality can be lessened through laparoscopic approaches. The need to convert to an open procedure may be increased for obstruction related to malignant disease [25,26]. Reports for laparoscopic palliative procedures are small [2427], and denitive conclusions are not available. Given the quality-of-life benets identied in the treatment of primary colorectal malignancies, minimally invasive approaches may allow more latitude in selection of surgical procedures. Averbach and Sugarbaker [4] advocate an aggressive approach to surgical palliation that entails maximal debulking and possible intraperitoneal chemotherapy for patients with symptomatic recurrent intra-abdominal cancer. Success is much more likely in patients who have low-grade tumors such as pseudomyxoma peritonii, complete cytoreduction, and a relatively long interval between primary surgery and the obstruction. It should be noted that their group reports that aggressive surgery is time-consuming (mean, greater than 10 hours), involves large blood losses (approximately 1500 cm3), and carries a high morbidity (55%), and mortality (7.14%). They advocate this treatment only in the most experienced hands. Because the authors focused on survival outcomes, it is not clear that these techniques improve overall quality of life or reduce symptoms. Therefore, it is difcult to interpret the role of these interventions for patients who have a disease with an aggressive biology and terminal status. Clearly, this treatment can be advocated only in a minority of the

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patients who present with intestinal obstruction in the palliative setting, but aggressive cytoreductive surgery can be considered in limited settings. During surgery for MBO, in addition to addressing the immediate problem of bowel obstruction, it is also important to anticipate other potential complications. Survival time, recurrent obstruction, treatment-related morbidity, nonobstructive symptoms, and quality-of-life considerations are all part of this calculation. In some cases, a combination of staged invasive approaches may be warranted. For example, initial stent placement may allow for later one-stage [28], laparoscopic [29], or open [30] resection in a more controlled and safe manner. At the time of operation, a venting gastrostomy may be used in addition to a resection or bypass procedure for a patient with carcinomatosis who is likely to become reobstructed but would not tolerate an additional invasive procedure.

SURGICAL OUTCOMES Resumption of oral intake following operation for MBO is variable and not well documented in the literature [10]. Patients who are chronically obstructed or have had a complicated procedure may not be ready to eat for a longer time. Others may be anorexic from cancer cachexia syndrome, which will not reverse unless the underlying cancer is eradicated. The inability to eat can prompt initiation of forced nutritional supplementation in patients with limited life expectancy. There are no simple solutions to this. There are few data to support forced nutrition in the setting of advanced, progressive cancer, although feeding and hydration are deeply emotional issues that have the potential for becoming ethical dilemmas. Although the total parenteral nutrition (TPN) in these settings may be considered and initiated, limitations should be set based on preoperative objectives (eg, ability to go home, eating with family, independence). TPN has not been shown to improve survival or nutritional parameters in the patient with advanced cancer, and malnourished patients may sustain increased complications from the central venous access that is necessary [31]. If TPN is instituted, enhancement of quality of life should be the measure of efcacy of this treatment. This standard is reached more readily if discussions about nutrition and hydration are part of the continuous process of shared decision making. Extended survival time often can be an expected secondary benet of the primary intention to surgically palliate symptoms of MBO. Unfortunately, survival time is frequently used as the only measure of success [8]. Although aggressive surgical approaches have been advocated, most outcomes have been reported as survival time and procedure-related morbidity, frequently omitting quality-of-life concerns. Operative mortality is frequent (5% to 32%), most often related to progression of neoplasm [5,10,32]. Morbidity is also common (42%) [32], and reobstruction after surgery may be quite high (10% to 50%) [10,33]. Although it is recognized that improvement in quality of life after surgery is variable

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(42% to 85%) [10,34], there is no consistent parameter used to determine this clinical outcome. Measures include the ability to tolerate solid food [12], the ability to tolerate oral feeding at discharge, the ability to resume a normal diet, restoration of bowel function, ability to return home, ability to live without a recurrent obstruction, and survival for more than 60 days [10]. Without uniform and clearly dened outcome measures, it is difcult to measure success. The primary goals of treatments are frequently multiple: the alleviation of pain, nausea, and vomiting. Outpatient care should be an important goal of therapy, no matter what treatment approach is initiated. Outpatient care depends on the availability of appropriate resources, including hospice and caretakers who are willing and able to take on the multiple tasks necessary to care for these patients, and on nancial and insurance limitations. Although it is important to be familiar with the retrospective literature related to MBO, the aims for surgical and other approaches must be considered and prioritized based on each individual patients and familys goals and desires. SUMMARY MBO is a common but difcult problem for surgeons caring for cancer patients. Nonsurgical interventions should be considered in all patients who have MBO, especially in those with limited expected survival time or for whom surgery will have little effect on disease control. Surgical options can be helpful in the setting of MBO, as long as reasonable goals and realistic outcomes are clear. There is no dened algorithm for all patients with MBO, and decision-making is based on reasonable estimates of survival and treatmentrelated success. Therefore, better prospective data need to be collected for this population of patients. In addition, a randomized prospective trial comparing treatments based on the clinical scenario could help practitioners who care for patients with this condition. References
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