Considerations in the Management Procedures of Malignant Large Bowel Obstruction; Surgical versus Conservative Management: Outcome and Prognostic Factors

Abstract

Introduction Malignant obstruction of the large bowel is a common clinical presentation, particularly in terminal cancer patients. Urgent resection and surgical diversion were the treatments of choice.

Objective The aim of the current study was to compare urgent resection of the colon and surgical diversion as conservative management in patients presented with malignant colorectal obstruction regarding short-term, post-operative, prognostic, and long-term oncologic outcomes.

Methods 80 patients with clinical and/or radiological evidence of malignant bowel obstruction distal to the ligament of Treitz and patients presented with incurable primary intra-abdominal primary cancer and patients with intra-peritoneal disease were included in the study. Patients were divided into 2 groups. The first group included 20 patients (25%) who underwent conservative management, while 60 patients (75%) underwent definitive surgical management.

Results We showed statistically significant findings between both groups regarding the total length of hospital stay, the total amount of costs, the rate, and the interval of re-admission. The duration of staying at hospital and rate of re-admission in the group that was managed by definitive surgery is more than the group of patients that was managed by conservation. We found that the rate of postoperative complications and morbidity in patients who underwent urgent definitive surgical resection was higher than that in those who underwent conservative management.

Conclusion In patients with malignant obstruction of the colon selection of definitive surgical management might not improve patients' outcomes and conservative management in addition to chemotherapy might be superior and might improve patients' outcomes and survival.

Keywords

malignant large bowel obstruction - surgical versus conservative management

Introduction

Malignant obstruction of the large bowel which is defined as the presence of clinical symptoms and signs of obstruction of the large bowel in association with concomitant evidence of primary or secondary intra-abdominal malignancy,[1] is considered a common clinical presentation, particularly in terminal cancer patients.[2]

The commonest primary malignancies that are usually complicated with bowel malignant obstruction are colorectal and gynecological malignancies.[3]

Such clinical problems are diagnosed by radiological investigation in addition to the established disease history. The presence of proximal intestinal loop distension with air-fluid level is the typical diagnostic radiological sign. Additionally, computed tomography (CT) produces higher specificity reaching up to 100% in detecting levels of obstruction.[4]

Urgent resection and surgical diversion were the treatment of choice in malignant obstruction of the large bowel before using a self-expanding metallic stent (SEMS).[2]

Treatment aims were digestive flow establishment, relieving compression symptoms, in addition to recovering the nutritional status.[5]

Former studies compared urgent resection and conservative surgical diversion, but results failed to show the superiority of either procedure.[6]

The current study aimed to compare urgent resection of the colon and surgical diversion as conservative management in patients presented with malignant colorectal obstruction regarding short-term, post-operative, prognostic, and long-term oncologic outcomes.

Methods

We included all patients who were presented with malignant obstruction of the colon and admitted to the general surgery department, Faculty of Medicine, Zagazig University in the period from May 2018 to May 2023

Inclusion Criteria

Patients with clinical and/or radiological evidence of malignant bowel obstruction distal to the ligament of Treitz and patients presented with incurable primary intra-abdominal primary cancer and patients with intra-peritoneal disease were included in the study.

Exclusion Criteria

Patients presented with non-malignant causes of obstruction, such as intra-abdominal adhesions, intussusception, obstructed or strangulated hernia, volvulus, and mesenteric vascular occlusions are not included in the present study.

We obtained approval for performing the present study from the institutional review board of the Faculty of Medicine, Zagazig University.

We obtained written informed consent from included patients or from their authorized persons for performing the study.

We collected all demographic data, physical examination data, and radiological, laboratory, and surgical findings.

Indication for surgery was mainly the failure of the conservative management therapy.

Surgical management procedures included definitive resection of the tumor or performing a stoma, according to specific intra-operative and intra-abdominal findings.

Statistical Analysis

We calculated the statistical data using SPSS 20.0 for Windows. We performed continuous data using the Shapiro–Wilk test for the detection of the distribution. We used the student t-test for normally distributed data and used the Mann–Whitney U-test for other data. We used the Chi-square test to compare differences in numeration data. We made survival analysis curves using the Kaplan–Meier method and Log-rank tests. We considered a P-value of less than 0.05 as statistically significant.

Results

This study included 80 patients with an age range from 21 to 88 years. Females represented 55% of them, 20 patients (25%) underwent conservative management, while 60 patients (75%) underwent definitive surgical management. [Tables 1] and [2]

Table 1 Baseline data of studied patients

	N = 80	%
Gender:
Female	44	55%
Male	36	45%
Age (year)	50.14 ± 18.57	21–88
Marital status
Unmarried	10	12.5%
Married	70	87.5%
Ascites	39	48.8%
Prior chemotherapy	47	58.8%
Prior radiotherapy	17	21.3%
Surgery	60	75%
TNM stage
I	0	0%
II	0	0%
III	9	11.3%
IV	71	88.7%
Approach
Conservative	20	25%
Surgery	60	75%

Table 2 Comparison between the studied groups regarding baseline data

	Group I N = 20 (%)	Group II N = 60 (%)	Test	p
Gender [n (%)] Female Male	13 (65%) 7 (35%)	31 (51.7%) 29 (48.3%)	1.077[¥]	0.299
Age (year) [median (IQR)]	57(31–75.5)	45(33–67)	-0.634[§]	0.526
Marital status [n (%)] Unmarried Married	3 (15%) 17 (85%)	7 (11.7%) 53 (88.3%)	0.152[¥]	0.696
Prior chemotherapy [n (%)]	14 (70%)	33 (55%)	1.393[¥]	0.238
Prior radiotherapy [n (%)]	4 (20%)	13 (21.7%)	Fisher [¥]	>0.999
Surgery [n (%)]	−	60 (100%)	−	−
Tumor resection [n (%)]	−	43 (71.7%)	−	−
Stoma [n (%)]	−	17 (28.3%)	−	−
TNM stage [n (%)] I II III IV	0 (0%) 0 (0%) 3 (15%) 17 (85%)	0 (0%) 0 (0%) 6 (10%) 54 (90%)	Fisher [¥]	0.684
ASA [median (IQR)]	1(1–2)	1(1–2)	-0.136[§]	0.892
CCI [median (IQR)]	6(5.25–7)	6(5–8)	-0.808[§]	0.419
Modified frailty index [median (IQR)]	3(2–4.75)	3(2–4)	-0.511[§]	0.61
Blood loss (ml) [median (IQR)]		210(50–355)
Operative time (hr) [median (IQR)]		4.63 ± 1.69

^¥ Chi square test.

^§ Mann Whitney test.

^∞ independent sample t-test.

We found no statistically significant findings between both surgical and conservative groups regarding demographic and baseline data.

There is a statistically significant difference between groups regarding length of hospital stay (significantly higher among group II) (p < 0.001**), readmission (65% within group I versus 31.7% within group II needed readmission) (p = 0.008), and time till readmission (significantly higher among group I).

Among group II, postoperative anastomotic leakage prevailed in 16.7%, three patients had surgical site infection, and five patients (8.3%) within group II died within 30 day postoperatively. [Table 3]

Table 3 Comparison between the studied groups regarding outcome parameters

	Group I N = 20 (%)	Group II N = 60 (%)	Test	p
LOS (day) [median (IQR)]	9(7.25–10.75)	21(15–29)	-5.701[§]	<0.001**
KPS [mean ± SD]
On admission	63.8 ± 14.65	62.82 ± 11.99	0.3[∞]	0.765
At discharge	62.6 ± 13.88	60.85 ± 12.27	0.534[∞]	0.595
PG-SGA [median (IQR)]
On admission	11(9.25–12)	10.5(7–13.75)	-0.519[¥]	0.604
At discharge	9(7.25–10)	8.5(5–11.75)	-0.496[¥]	0.62
TPN [n (%)]	10 (50%)	34 (56.7%)	0.269[¥]	0.603
EN [n (%)]	17 (85%)	53 (88.3%)	Fisher[¥]	0.705
Ascites [n (%)]	8 (40%)	31 (51.7%)	0.817[¥]	0.366
Postoperative anastomotic leakage [n (%)]		10 (16.7%)	−	−
Surgical site infection [n (%)]		3 (5%)	−	−
Readmission [n (%)]	13 (65%)	19 (31.7%)	6.944	0.008*
Interval till admission (day) [median (IQR)]	17(8.25–21)	6 (4–12)	-2.5[§]	0.012*
Receive solid food [n (%)]		45 (75%)
Time till receive solid food [median (IQR)]		9(6–14.5)
Postoperative 30-day mortality [n (%)]	0 (0%)	5 (8.3%)	Fisher [¥]	0.324

^¥ Chi square test.

^§ Mann Whitney test.

^∞ independent sample t-test.

^* p < 0.05 is statistically significant.

The 30-day post-operative mortality rate in patients managed by definitive surgery was 10%.

The most performed surgical procedures in the definitive surgery group were segmental colectomy (60%) and Hartmann's operation (7%).

About 25% of urgent resections were laparoscopically assisted.

Postoperative Morbidity

We found no statistical significance between both groups regarding postoperative morbidity rate, anastomotic leakage rate, or mortality rate but the rate of postoperative complications and morbidity in patients who underwent urgent definitive surgical resection was higher than that in those who underwent conservative management.

We found a statistically significant difference between both groups regarding the incidence of permanent stoma as patients who underwent definitive surgical resection were more liable to be left with a permanent stoma in comparison to patients undergoing conservative management.

Long-Term Oncologic and Survival Analysis

There is a statistically non-significant difference between groups regarding overall survival. The mean OS within group I was 374.29 days versus 190.88 days within group II.

Patients who underwent definitive surgical resection have a shorter five-year OS rate than patients who underwent conservative management. [Table 4]

Table 4 Comparison between the studied groups regarding overall survival

	Total	Events	Censored (%)	Estimate ± SD	95% CI	P
Conservative group	20	1	19(95%)	374.29 ± 23.81	327.62–420.95	0.058
Surgical management group	60	7	53(88.3%)	190.88 ± 14.73	162.02–219.74
Overall	80	8	72(90%)	334.82 ± 25.31	285.21–384.42

P for log rank test.

Discussion

Screening programs for early detection and management of colon polyps and thus early detection of colorectal cancers were interrupted during and after the COVID-19 pandemic which lead to an increasing prevalence of malignant obstruction of the bowel.[5] There are many options for management as; definitive urgent surgical management and conservative decompression management. Many studies demonstrated that surgical management was not superior to conservative management.

In the present study, we showed that total length of hospital stays, and medical costs were higher in the surgical group and showed that rates and interval of re-admission were lower in the surgical group than in the conservative group without significant differences between both groups regarding survival rates. Our data were similar to the results of McKechnie et al.,[5] and Yu et al.[2]

We showed that decision-making depends on several individualized patients and tumor factors.

As, overall patient's health status, age, expected survival rate, and history of radiotherapy or chemotherapy.

It was demonstrated that in young patients with good general status who can afford the surgical procedure, surgery was recommended for the establishment of the flow of the gastrointestinal tract and relieving the occlusion in the digestive system.[7]

Our results and results of most previous studies showed that patients who underwent definitive surgical management were found to have lower survival rates, though these results were without statistically significant, but these results pointed to that surgery wouldn't improve patients' survival rate even in patients fit for surgical intervention.[8] [9]

Smith et al.,[10] demonstrated that surgical resection improves patients' outcomes more than conservative management, these results were slightly different from our results and explained by; patients' selection criteria and previous intake of neo-adjuvant therapy. In the present study, we highlighted the role of previous intake of therapy in cases with malignant bowel obstruction as combined chemotherapy and surgical intervention could improve patient's outcome and survival in comparison to surgery alone.[11]

Similar to previous studies we showed that management of patients with malignant bowel obstruction must be individualized according to the patient's age, general condition, and comorbidities.[7] [8] [9] [10] [11] Moreover previous reports showed that laparoscopic resection will be safe and feasible.[12] [13]

Limitations of the study: first its retrospective nature so its results and conclusions could not be generalized into other circumstances. Secondary detailed molecular evaluation of biological pathways in included patients was not analyzed.

Recommendations: we recommend performing large-scale studies evaluating patients with malignant bowel obstruction who underwent surgical or conservative management including evaluation of the role of molecular parameters to discover future accurate prognostic markers for such patients

Conclusion

In the present study, we showed that in patients with malignant obstruction of the colon selection of definitive surgical management might not improve patients' outcomes, and conservative management in addition to chemotherapy might be superior and might improve patients' outcomes and survival.

Fig. 1 Kaplan Meir survival curve showed the survival rate of both groups.

Conflict of Interest

None declared.

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Publication History

Received: 18 June 2024

Accepted: 24 October 2024

Article published online:
18 December 2024