When the sun can set on an unoperated bowel obstruction: management of malignant bowel obstruction.

Mr XY is a 75-year-old man with known recurrent rectosigmoid adenocarcinoma in the pelvis. He had an emergency Hartmann’s procedure 2 years earlier for a bowel perforation caused by tumor. The patient had been offered a surgical intervention 3 months earlier for the recurrent pelvic mass visualized on CT, but he declined any additional surgical intervention. No metastatic disease was noted at that time. He had no symptoms of bowel obstruction at the time, although there were signs of minimal proximal bowel dilatation. He presented to the Emergency Department on three separate occasions in a 3-week period with nausea, vomiting, abdominal cramping, and no colostomy output. A partial small bowel obstruction was confirmed on plain film x-rays. Clinically, the patient was in good condition and had no physical inhibitions. He was treated with nasogastric decompression on each occasion and the symptoms quickly resolved and bowel function resumed. On the first two occasions, he was able to eat a regular diet and return home within 3 to 5 days of being admitted to the hospital. He had a small bowel follow-through after the second obstruction episode, which was nondiagnostic. After the third episode, a lengthy conversation was undertaken with the patient about his goals and concerns related to an operation. This revealed fears of the pain related to surgery. After discussion about the likelihood of continued episodes of bowel obstruction and the assurance that diligent perioperative pain management would be practiced, including the possible use of an epidural catheter, he agreed to have an operation. The goals of restoring his capacity to eat, and the hope of allowing him to remain home without multiple readmissions to the hospital, were clearly delineated. We believed that the obstruction was most likely from a single site at his pelvic recurrence, and we were likely to achieve these goals. It was made clear to the patient that he could have more disease or adhesions than expected, making a definitive surgical approach difficult or impossible, and necessitating alternative therapies. He was told that even with surgery, bowel obstruction and wound complications could occur in the future. At operation, there were extremely dense adhesions throughout his entire peritoneal cavity, especially in the pelvis. He did not have peritoneal carcinomatosis, although he did have tumor nodules throughout his liver. The source of the bowel obstruction was difficult to locate because no area of decompressed bowel was found, and extensive adhesiolysis was required. The colostomy site was closely inspected to ensure that it was not the site of obstruction. Ultimately, a loop of very distal small bowel was adherent to a pelvic tumor mass overlaying the iliac vessels and ureter. The small bowel was folded on itself, creating a small blind loop. The decision was made to do a small resection instead of a bypass.This was accomplished with a primary anastamosis without complication. Postoperatively, the patient’s bowel function was slow to resume. Otherwise, he recovered uneventfully and went home 8 days after the operation. One month after operation he remains at home without symptoms or signs of recurrent bowel obstruction.