IN ADVANCED STAGE CANCER ESDO Learning Bytes 2021 PieterJan CUYLE Gastroenterology Dep Imelda Hospital Bonheiden Belgium Digestive Oncology Dep University Hospitals Leuven Leuven Belgium ID: 1047951
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1. MALIGNANT BOWEL OBSTRUCTIONIN ADVANCED STAGE CANCERESDO Learning Bytes 2021Pieter-Jan CUYLEGastroenterology Dep., Imelda Hospital, Bonheiden, BelgiumDigestive Oncology Dep., University Hospitals Leuven, Leuven, Belgium
2. SCOPE OF THE PROBLEMDIAGNOSTIC STEPSDECISION MAKINGMANAGEMENTMALIGNANT BOWEL OBSTRUCTION - CONTENT
3. MALIGNANT BOWEL OBSTRUCTION - SCOPE OF THE PROBLEMMBO = bowel obstruction due to cancer or its treatmentnauseavomitingcolic like painabdominal distensionlack of flatus/stools 3 – 15% of all advanced stage cancershigh incidence in advanced GYN and GI cancersSTRANGULATION (bowel ischaemia) and/or BOWEL PERFORATIONprofound effect on QUALITY of LIFEMALNUTRITION with cachexia/sarcopeniaDIFFICULT MANAGEMENT IN ADVANCED STAGE CANCER< deteriorating mobility/function (performance status)< lack of further anti-cancer treatment options< high morbidity/mortality of palliative surgery< lack of high level scientific guidance/evidenceHuang X., et al. Ann Pharmacother 2020
4. MALIGNANT BOWEL OBSTRUCTION - DIAGNOSTIC STEPS2. CAUSEsmall bowel (61%) – large bowel (33%) – both (>20%) 1. LOCATIONMBO = contrast enhanced CT scan of abdomen and pelvis3. PARTIAL or COMPLETE4. UNILEVEL or MULTILEVEL5. ISCHAEMIA or PERFORATIONCANCER RELATED1/ EXTRINSIC bowel compression < malignant mass or adhesions2/ ENDOLUMINAL obstruction < polyp or GI tumor < radiotherapy induced fibrosis3/ FUNCTIONAL obstruction < enteric nerve plexus invasion < drug induced < paraneoplasticNON-CANCER RELATEDe.g. incarcerated inguinal herniaFerguson H., et al. Ann Med Surg (Lond.) 2015
5. TREATMENT GOAL1. MALIGNANT DISEASE EXTENSION2. GENERAL PROGNOSIS3. REMAINING TREATMENT OPTIONS1. LOCATION2. CAUSE3. PARTIAL or COMPLETE4. UNILEVEL or MULTILEVEL5. ISCHAEMIA or PERFORATIONMALIGNANT BOWEL OBSTRUCTION - DECISION MAKINGMBO decision making = MULTIDISCIPLINARY TEAMOBSTRUCTION RELATED factorsCANCER RELATED factors1. PATIENT CHARACTERISTICS (age, comorbidity, performance status)2. PATIENT PREFERENCEPATIENT RELATED factors(experienced) abdominal surgeryoncologygastroenterology/endoscopyradiologyradiotherapypalliative care specialistMDT
6. MALIGNANT BOWEL OBSTRUCTION - MANAGEMENTMBO management = low level scientific evidenceMDT decision makingnihil per osfluid and electrolyte replacementNON-SURGICAL CANDIDATE (inoperable)SURGICAL CANDIDATEMEDICAL MANAGEMENTINITIAL RESUSCIATIVE MEASURESDIAGNOSTIC CT SCANSURGICAL MANAGEMENTTIMINGTYPEbowel resection and anastomosisdiverting stoma placement (ileostomy to be avoided)internal bypass surgery
7. MALIGNANT BOWEL OBSTRUCTION – MEDICAL MANAGEMENTacute: nasogastric (-intestinal) suction tubechronic: percutaneous ‘venting’ gastrostomyNON-SURGICAL CANDIDATE (inoperable)MEDICAL MANAGEMENT1. BOWEL DECOMPRESSION2. PHARMACOLOGICALcave use of prokinetics in complete obstruction3. NUTRITIONAL SUPPORT4. THERAPEUTIC ENDOSCOPYANTI-EMETICSANTI-SECRETORYANTI-INFLAMMATORYPPI, anticholinergics, H2-blocker, somatostatine analoguecorticosteroidsANALGETICSANTIBIOTICScave translocation in immunosuppressed patientsReview article – Medical management of inoperable malignant bowel obstruction – Huang X., et al. Ann Pharmacother 2020Thampy S., et al. J Palliat Care 2020
8. MALIGNANT BOWEL OBSTRUCTION – MEDICAL MANAGEMENTNON-SURGICAL CANDIDATE (inoperable)MEDICAL MANAGEMENTuncoveredpartially coveredfully covered stentsstent re-occlusionstent migrationperforation (cave. use anti-VEGF targeted agents)4. THERAPEUTIC ENDOSCOPYSELF-EXPANDABLE METAL STENT (SEMS)for lesions “within reach” of the endoscope (except distal rectum)1. reinstitution of natural luminal passage2. endoscopic bypass procedureItoi T., et al. Gut 2015Braga Ribeiro I., et al. World J Gastrointest Endosc 2019AGA clinical practice guidelines. Ahmed O. et al. Clin Gastroenterol Hepatol 2021
9. MBO is prevalent in advanced stage cancer and is associated with profound impact on QoL and prognosis of patients.Contrast enhanced CT of abdomen and pelvis remains the gold standard in diagnostic and therapeutic assessment of MBO.Therapeutic decision making in MBO is often difficult and needs to be undertaken in the context of an experienced multidisciplinary team.MALIGNANT BOWEL OBSTRUCTION – TAKE HOME MESSAGES