Malignant

bowel obstruction
(MBO) syndrome


MBO has been defined using the

following criteria:
-clinical evidence of bowel
obstruction,
-obstruction beyond the ligament of
Treitz (in the setting of intraabdominal cancer with incurable
disease), or nonintraabdominal
primary cancer with clear
intraperitoneal disease.
1. Anthony T, Baron T, Mercadante S, et al. Report of the clinical protocol committee: development of
randomized trials for malignant bowel obstruction. J Pain Symptom Manage 2007;34(1
suppl):S49S59. [17544243]


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MBO can be a challenging condition in advanced cancer
patients and is most common with ovarian tumors (5%
42%) and colorectal tumors (4%24%)

Intestinal involvement of metastatic cancer commonly
presents as diffuse peritoneal carcinomatosis or more
rarely (~10% of cases) as an isolated gastrointestinal
metastasis.

Breast cancer or melanoma are the most common non-gastrointestinal causes of MBO and can occur
many years from primary presentation.
1. Ripamonti C, Bruera E. Palliative management of malignant bowel obstruction. Int J
Gynecol Cancer 2002;12:135143. [11975672]
2. Idelevich E, Kashtan H, Mavor E, Brenner B. Small bowel obstruction caused by
secondary tumors. Surg Oncol 2006;15:2932. [16905310]



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When the obstruction was multifocal, it
involved both the small and large
bowels in 79% of cases, the small bowel
alone in 13%, and the large bowel
exclusively in 8%
Dvoretsky PM, Richards KA, Bonfiglio TA. The pathology and biologic behavior of ovarian cancer. Pathol Annu
1989;24:124.
2. Dvoretsky PM, Richards KA, Angel C, et al. Survival time, causes of death, and tumor/treatmentrelated morbidity
in 100 women with ovarian cancer.Hum Pathol 1988;19:12731279.
3. Dvoretsky PM, Richards KA, Angel C, et al.Distribution of disease at autopsy in 100 women with ovarian cancer.
Hum Pathol 1988;19:5763.
1.





( 93%,
100%, 94%)
0.5 ,
. 21%
[1]

( 93-95%, 63-100%, 8196%)

1. Taorel PG, Fabre JM, Pradel JA, et al. Value of CT in the diagnosis and management of patients with suspected acute
small bowel obstruction. AJR Am J Roentgenol 1995;165:11871192. [7572500]




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In historic case series, up to 50% of
bowel obstructions in cancer patients were
due to a benign etiology, such as an adhesive
band or hernia.

In surgical series, as many as 23% of
patients with ovarian cancer are found to have
a non-malignant cause of obstruction at the
time of surgery.

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(Tunca et al. found that the median survival time of patients managed by
surgical intestinal bypass versus resection and anastomosis was almost
identical, and that the degree of obstruction (ie, partial or complete) was
not significantly related to survival)


The management of patients with MBO is influenced by

the level of obstruction,

pattern of disease,

clinical stage of cancer

overall prognosis,

prior and potentially future anti-cancer treatments,

patients health and performance status,

tumour biology,

quality of life.
Because the management of MBO is rarely an
emergency, time can and should be taken to come up
with an appropriate treatment plan.
!!!



1. Is palliative surgery technically feasible?
2. Rates of operative morbidity and
mortality.
3. Risk of repeat obstruction.
4. Ability to administer future
chemotherapy.
5. Is the patient likely to benefit from
surgery not only in terms of survival but
above all in terms of quality of life?



survival of 30 or 60 days after an
intervention

rate of hospital discharge

the ability to tolerate oral supplementation for a given length of time (30 or 60
days)

quality of life

quality of death

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In much of the surgical literature, benefit from
surgery is defined as at least 60 days of
survival after the operation. However, the
assessment of quality of life, re-obstructions,
symptom control, and patient overall comfort,
have not been considered in most publications.

Published data shows that patients with
advanced cancer have an operative mortality
of 940% and a complication rate of 990%.
Neither the site of the obstruction nor the type
of operation influenced survival

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1. Obstruction secondary to cancer

2. Intestinal motility problems due to diffuse intraperitoneal carcinomatosis
3. Widespread tumor
4. Patients over 65 year in association with cachexia
5. Ascites requiring frequent paracentesis
6. Low serum albumin level (31) and low serum prealbumin level
7. Previous radiotherapy of the abdomen or pelvis
8. Patients with nutritional deficits
9. Diffuse palpable intra-abdominal masses and liver involvement
10. Distant metastases, pleural effusion or pulmonary metastases
11. Multiple partial bowel obstruction with prolonged passage time on radiograph xamination
12. Elevated blood urea nitrogen levels, elevated alkaline phosphatase levels, advanced tumor
stage, short diagnosis to obstruction interval
13. Poor performance status
14. A recent laparotomy which demonstrated that further corrective surgery was not possible
15. Previous abdominal surgery which showed diffuse metastatic cancer
16. Involvement of proximal stomach
17. Extra-abdominal metastases producing symptoms which are difficult to control (e.g.,
dyspnea)

Patients with two or more poor prognostic factors can have an operative mortality of 44%,
as compared to 13% among those with one or less risk factors
Ripamonti et al. 2001


enterocutaneous fistulas
anastomotic leaks
short bowel syndrome
sepsis
abscess formation, necessitating CT- guided
drainage

bacterial peritonitis

pulmonary embolism
were noted in 22 - 32% of good selected patients



71% of those patients who underwent surgical correction of their
obstruction were indeed able to tolerate a low-residue or regular
diet 60 days postoperatively. These patients had a statistically
significant prolongation of survival, compared with those who were
not successfully palliated (11.6 months vs 3.9 months, P .01). Our
extension of survival compared with prior studies may be
attributable to improved patient selection for surgery and perhaps
the ability to tolerate chemotherapy after surgery [1].

Another study indicated that survival time was also related to the
response of patients to postoperative chemotherapy rather than the type
of surgery performed (ie, enterocolonic bypass, ileostomy, smallintestinal
resection, colostomy) [2].

1.

Palliative surgery for bowel obstruction in recurrent ovarian cancer: an updated series, Bhavana Pothuri at all. Gynecologic Oncology
89 (2003) 306313
Piver MS, Barlow JJ, Lele SB, Frank A. Survival after ovarian cancer induced intestinal obstruction. Gynecol Oncol 1982;13:449.

2.



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Results of systematic reviews of efficacy andsafety of colorectal stenting in the
management of acute malignant colorectal obstruction
Khot et al.

Sebastian et al.

Technical success

551 (92%)

1198 (94%)

Clinical success

525 (88%)

1198 (91%)

301/336 (90%)

791 (93%)

3 (1%)

7 (0.6%)

22 (4%)

45 (3.8%)

Stent migration

54 (10 %)

132 (11.8%)

Re-obstruction

53 (10%)

82 (7.3%)

Palliative success
Deaths
Perforation

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94% had PEGs successfully placed and 84.4%
had resolution of symptoms, with return of the
bility to consume liquids or soft food for a median
of 74 days. In a retrospective study, 42 28 Fr.
PEG tube placement was feasible in 98% of
patients with advanced recurrent ovarian cancer,
even in patients with tumour encasing the
stomach, diffuse carcinomatosis and ascites.
1. Campagnutta E, Cannizzaro R, Gallo A, Zarrelli A, Valentini M, De Cicco M, et al. Palliative Treatment of Upper Intestinal Obstruction by Gynecological
Malignancy: The Usefulness of Percutaneous Endoscopic Gastrostomy. Gynecologic Oncology 1996;62:1035.
2. Pothuri B, Montemarano M, Gerardi M, Shike M, Ben-Porat L, Sabbatinin P, et al. Percutaneous endoscopic gastrostomy tube placement in patients with
malignant bowel obstruction due to ovarian carcinoma. Gynecologic Oncology 2005;96:3304



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dexamethasone (12 mg/d)

octreotide (0.3 mg/d),
metoclopramide (60 mg/d),
Gastrografin (diatrizoate meglumine and diatrizoate sodium);
hydration 1,500 mg/d
morphine or transdermal fentanyl [Duragesic]
non-steroidal anti-inflammatory agents.

In a study of 27 consecutive patients with noperable MBO

(Mercadante S et al. J Pain Symptom Manage 2004;28:412416),
this combination produced a 90% recovery rate. Patients maintained
on the combination had survival prolonged from 75 days (with
placebo) to 187 days

Patients with recent gastrointestinal

symptoms - potentially reversible
bowel obstruction
Octreotide 0.3 mg/day (0.1 mg three times a
day) intravenously or subcutaneously
Dexamethasone 4 mg three times a day
intravenously or subcutaneously
Metoclopramide 60120 mg intravenously or
subcutaneously
Amidotrizoate 3050 mL orally
( )
Maintain metoclopramide-octreotide regimen
according to the clinical evolution.

Patients with persistent gastrointestinal

symptoms, inoperable - early treatment
unsuccessful - definitive obstruction
Stop metoclopramide
Octreotide 0.3 mg daily (0.1 mg three times a
day) intravenously or subcutaneously; increase
dosage up to 0.9 mg/day, if partially successful
Haloperidol 25 mg/day intravenously or
subcutaneously
Parenteral or transdermal opioid analgesics
Also consider venting gastrostomy, if surgically
feasible

Patients undergoing surgery for bowel

obstruction - preoperative use
Octreotide 0.3 mg/day (0.1 mg three times a day)
intravenously until surgery
Intravenous hydration with plasma expanders
and electrolyte correction
Decompressive nasogastric tube
Antibiotics, including a cephalosporin and
metronidazole
Maintain octreotide for the first 24-48 hours
ostoperatively.

Analgesics, selected and

dosed according to World
Health Organization (WHO)
guidelines

Anticholinergics

scopolamine butylbromide (., -, - )

scopolamine hydrobromide

Antisecretory agents

Anticholinergics
scopolamine butylbromide (40120 mg/day)
scopolamine hydrobromide (0.82.0
mg/day)
glycopyrrolate (0.10.2 mg tid
subcutaneously
or intravenously)
and/or

ctreotide (0.20.9 mg/day via continuous
subcutaneous or intravenous infusion)

Antiemetics

etoclopramide (use only in patients with

partial obstruction and no colicky ain)

Neuroleptics

aloperidol (515 mg/day via continuous

subcutaneous infusion)
ethotrimeprazine (50150 mg/day via
continuous subcutaneous infusion)
rochlorperazine (2575 mg/day rectally)*
hlorpromazine (50100 mg/8 h rectally or
subcutaneously)*()

Antihistaminic agents

yclizine (100150 mg/day (50100 mg/day

subcutaneously or rectally)
dimenhydrinate (50100 mg/day
subcutaneously)

Continuous pain

Colicky pain

Nausea
Vomiting

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Octreotide can be useful preoperatively in optimizing the obstructed
patients condition, along with intravenous replacement of fluids
and electrolytes, placement of a nasogastric tube, and use of
antibiotics. One study of patients treated in this fashion
showed that the diameter of the bowel above the obstruction
returned to normal, with no local gross pathologic findings,
such as edema, vessel congestion, or bowel necrosis. Samples of
intestine above and below the obstruction revealed normal
anatomic and biochemical patterns. Intestinal anastomosis
after resection was successful. These preliminary results were
confirmed in a randomized, double-blind clinical trial carried
out on 54 consecutive patients with mechanical bowel
obstruction. Patients who received octreotide prior to planned
surgery required surgery less often than patients who did not
receive the drug. Moreover, severe dilatation and necrosis of the
bowel proximal to the area of obstruction were significantly less
common in the octreotide-treated patients than in those who did
not receive the drug preoperatively.



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An analysis of surgical versus chemotherapeutic

intervention for the management of intestinal obstruction
in advanced ovarian cancer
Int J Gynecol Cancer 2006, 16, 125134
Obstruction site and
treatment approach

Number of
obstruction events

Small bowel

79 (81%)

Successful
palliations

Chemotherapy

31 (39%)

10/31 (32%)

Surgery

26 (33%)

2/18 (11%)

Supportive

22 (28%)

2/18 (11%)

Unknown

0 (0%)

12

Large bowel

8 (8%)

Chemotherapy

0 (0%)

Surgery

7 (88%)

4/5 (80%)

Supportive

1 (12%)

0/1 (0%)

Unknown

0 (0%)

Both

11 (11%)

Chemotherapy

1 (9%)

1/1 (100%)

Surgery

8 (73%)

0/4 (0%)

Supportive

2 (18%)

0/1 (0%)

Unknown

0 (0%)

98

19/79 (24%)

Total

Retrospective analysis of 39 patients with

epithelial ovarian cancer who had 98 events of
intestinal obstruction was performed
Prior to first obstruction, the median number of
prior surgeries was 2 and chemotherapy regimens
3
Sites of the 98 events of obstruction were small
intestine, 79 (81%); large intestine, 8 (8%); and
combined small and large intestines, 11 (11%)
The only significant factor predictive of 6 month
obstruction-free period was prior response to
platinum-based chemotherapy

mean time to
reobstruction

6.4 months
(0 - 24)

5.1months
(040)

1.9 months
(015)

mean hospital
stays

7 days
(210)

18 days
(350)

7 days
(020)

major
complications

11

?

In this retrospective analysis of selected
patients, surgery and chemotherapy were
found to have similar outcomes, while the
surgical approach had higher morbidity.
The best predictor of either treatments
effectiveness was tumor sensitivity to
platinum-based chemotherapeutic
agents.