Recommendations for the Multimodal Management of Malignant Bowel Obstructions: Results of a North American Multidisciplinary Delphi Consensus

Abstract Background Malignant bowel obstruction (MBO) is a challenging clinical problem requiring teams to balance complex oncologic disease, limited treatment options, and patient prognosis and values as they approach end of life. Presently, there is limited high-quality evidence to guide decision-making for MBO patients. Objective A multidisciplinary modified Delphi process was undertaken to create guidance and support clinical decision-making in the medical and surgical care of this patient population. Methods Multidisciplinary experts from all specialties regularly caring for MBO in Canada and the United States were invited for participation, including Acute Care Surgery, Surgical Oncology, Gynecologic Oncology, Gastroenterology, Radiology, Medical Oncology, and Palliative Care. Statements were evaluated through two rounds of surveys and a consensus meeting, with an a priori threshold of 80% agreement for approval. Results Forty-nine final evidence-informed statements were included following expert consensus review pertaining to Patient Assessment, Medical Management, Surgical Management, and Palliative Management, in addition to a unifying definition of MBO. Consensus statements address aspects of complex MBO care, including but not limited to, optimal preoperative evaluation and multidisciplinary review; timing and use of steroids, motility, and antisecretory agents; contraindications to surgery; key facets of consent and perioperative decision making; framework for the nuanced use of gastrostomies and IV fluids in the end-of-life setting. Conclusions This Modified Delphi consensus provides multidisciplinary evidence-based recommendations for the care of patients with this challenging problem. These expert approved statements provide much-needed clinical guidance to support best care balanced with patient values and avoidance of undue harm.