Malignant Bowel Obstruction: Historical Lessons, Current Trends, and Future Directions

Malignant bowel obstruction (MBO) is defined as a mechanical/functional/radiologic obstruction of the gastrointestinal tract beyond the Ligament of Treitz in the presence of a known primary or metastatic abdominopelvic malignancy. Though numerous retrospective studies have been conducted on the outcomes of various treatment modalities, there is a tremendous heterogeneity of MBO definitions, clinical presentations, and offered treatments. Few prospective studies or randomized trials exist, making it difficult to ascertain generalizable data and develop applicable clinical guidelines. In this review, a systematic computerized search was conducted on PubMed for high quality data on MBO epidemiology, pathophysiology, and treatment modalities, with a particular focus on comprehensive systematic literature reviews. The current standard of care for medical, surgical, and endoscopic treatment of MBO was discussed in detail. Historical data was contextualized and the latest findings of the first randomized-controlled clinical trial (SWOG S1316) studying surgical vs. non-surgical treatment of MBO was critically appraised. These findings give insight on how to optimize future trial design, measure comprehensive quality of life outcomes, and develop clinical practice guidelines in line with patient-specific goals of treatment. Synopsis Malignant bowel obstruction (MBO) is a complex clinical entity with high rates of morbidity and mortality. Many retrospective studies of MBO management exist in the literature, however there are relatively few established clinical practice guidelines. Specifically, there is a shortage of randomized clinical trials comparing surgical and non-surgical treatment. This review summarizes the current state of the literature, discusses the first randomized-controlled clinical trial on the surgical management of MBO, and suggests future directions for investigation.